Failure to Provide Ordered Tube Feedings and Safe Positioning During Enteral Nutrition
Summary
Surveyors identified that the facility failed to ensure residents receiving tube feeding were provided nutrition as ordered and that tube feeding formula and equipment were properly maintained. One resident with dysphagia oropharyngeal phase had a continuous order for Jevity 1.5 at 65 ml/hr. Multiple observations over several days showed that factory-sealed 1500 ml bottles of Jevity 1.5, labeled with hang times, were not infusing at the ordered rate despite the pump being set correctly. Large volumes of formula remained in the bottles when significant amounts should have infused based on the documented start times and ordered rate, and on at least two occasions the same bottle remained hanging for over 24 hours. The pump was observed alarming “inactive” or “cassette error” with no formula infusing, yet the same bottles continued to hang, and staff did not replace the formula or tubing within the 24-hour timeframe. The observations for this resident showed repeated instances where the amount of formula remaining in the bottle did not match what should have been delivered according to the physician’s order and elapsed time. For example, a bottle hung the previous evening still had nearly the full volume present the next morning, and later in the day the same bottle continued to show minimal infusion despite the pump being set at 65 ml/hr. On another day, a bottle hung early in the morning still had almost the entire volume remaining several hours later while the pump alarmed with an error and no feeding was infusing. On subsequent observation, the same bottle remained in use more than 24 hours after it was hung, with substantial formula still present when, by calculation, the entire bottle plus additional formula should have infused. Staff interviews confirmed that tube feeding bottles and tubing were supposed to be changed at least every 24 hours and that formula should not hang longer than that. Surveyors also found that another resident with a history of pneumonia, stroke, and hemiplegia/hemiparesis, who had an order for continuous Jevity 1.5 at 60 ml/hr via pump with allowance for disconnection for care, received personal care while the tube feeding continued to infuse and the head of bed was lowered. On two separate observations, a CNA entered the room, donned gloves, and lowered the resident’s head of bed to provide personal care while the tube feeding continued without being paused. After care, the CNA then repositioned the resident and elevated the head of bed. During one of these episodes, a Wound Nurse was present for a skin assessment and did not pause the feeding or instruct the CNA to avoid lowering the head of bed while the feeding was running. In interviews, nursing staff, including an LPN and the DON, stated that CNAs should notify the nurse so the pump can be turned off during care and that allowing tube feeding to infuse with the head of bed low increases the risk of aspiration.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a g-tube, dysphagia, and malnutrition had an enteral feeding order that omitted the formula strength and the administration method. The chart showed the resident was receiving Isosource 1.5 cal bolus feedings, but the active order only stated enteral feed via g-tube. The MDS Coordinator, LVN, and DON all acknowledged the order was incomplete, and the facility policy required enteral nutrition orders to include the product and administration method.
A resident with a GT, GERD, interstitial pulmonary disease, and dementia was observed receiving medications via the GT without the nurse confirming tube placement. The LVN stated she did not check GRV before administering the medications, and the RN and DON stated GT placement and residuals should be checked prior to medication administration, although the facility policy did not include GRV checking.
Inadequate G-tube care and enteral feeding documentation. A resident with CVA-related hemiplegia and dysphagia had orders for NPO status, continuous Jevity 1.5 via G-tube, water flushes, residual checks every shift, and oral care, but the record lacked an order for tube placement verification or shift site care. MAR/TAR review showed no consistent documentation of G-tube site care or residual checks, water flushes were not always documented as ordered, and feeding amounts were recorded in two places with inconsistent entries; nursing notes were also not present for every shift.
A resident with a g-tube, severe cognitive impairment, and dependence on staff for all nutrition and hydration did not receive continuous tube feeding at the ordered start time. The feeding pump was observed off while the resident was away from his room and remained off after he returned from the Day Center; an LVN later connected the feeding after changing the g-tube dressing. Staff stated the resident often returned after the ordered start time and was therefore not hooked up as ordered.
A resident with a G-tube was observed lying supine and below 30 degrees while enteral feeding was running. A CNA said the resident was lower than she should have been during the feeding and that the tube feeding should be turned off when repositioning is needed. An LVN later confirmed the resident should not be lying flat during feeding, paused the tube feeding, and said the resident needed assistance to be safely elevated; the DON stated the head should be elevated above 30 to 45 degrees and never flat during feeding.
Failure to Verify G-Tube Placement Before Medications and Water Administration: An LPN administered crushed meds and water through a resident’s PEG tube without routinely checking tube placement first. The resident had dysphagia, cognitive impairment, and received most calories and fluids via the feeding tube. The RN and DON also indicated uncertainty about whether placement checks were still required, and no provider order exempting the resident from placement verification was found, despite the facility policy requiring placement checks before tube feedings and meds.
Incomplete Enteral Feeding Order for Resident with G-Tube
Penalty
Summary
The facility failed to ensure that Resident #4, a male with a gastrostomy tube, unspecified protein-calorie malnutrition, and sequelae of protein-calorie malnutrition, received an enteral feeding order that included the formula strength and the specific administration method. Resident #4's significant change MDS reflected that he rarely or never made himself understood, sometimes understood others, and had long- and short-term memory problems. His care plan identified that he required tube feeding related to dysphagia and that tube feedings were to be administered per physician orders. The physician order summary dated 06/30/26 listed an active order for enteral feed four times daily via g-tube, but it omitted the Isosource strength and did not specify whether the feeding was to be given by bolus or pump. Hospice physician orders dated 06/19/26 were more specific and identified Isosource 1.5, four times daily. During interviews, the MDS Coordinator stated nursing staff had been administering Isosource 1.5 cal bolus feedings via g-tube. The LVN and DON both acknowledged the order was missing the strength and administration method, and the DON stated she could not recall whether she had added the administration method when updating the order. The facility policy on enteral nutrition stated complete orders include the enteral nutrition product and the administration method.
Failure to Verify GT Placement Before Medication Administration
Penalty
Summary
The facility failed to ensure appropriate gastrostomy tube care for Resident 9 by not confirming GT placement before medication administration. Resident 9 was admitted and later readmitted with diagnoses including gastrostomy status, GERD, interstitial pulmonary disease, and dementia. The MDS dated 3/30/26 indicated the resident was severely impaired in cognitive skills for daily decision making, dependent for multiple activities of daily living, and had a feeding tube with a therapeutic diet. Physician orders dated 2/21/2026 directed continuous enteral feeding of Jevity 1.2 at 40 ml/hour for 20 hours via GT. During a concurrent observation and interview on 7/1/2026 at 9:51 AM, LVN 5 was observed preparing and administering medications to Resident 9 without confirming GT placement. LVN 5 stated she did not check the resident's gastric residual volume prior to giving medications, but should have done so to prevent aspiration. RN 2 and the DON later stated that GT placement and residuals should be checked prior to medication administration, and both acknowledged that checking GRV was not included in the facility policy even though the policy stated tube placement should be verified before administering fluids or medications.
Inadequate G-tube care and enteral feeding documentation
Penalty
Summary
Appropriate care and services were not provided for a resident receiving tube feedings. Resident 7 had diagnoses including cerebral infarction with right-sided hemiplegia and hemiparesis and dysphagia, and had orders for NPO status, continuous Jevity 1.5 enteral feeding via G-tube, water flushes, residual checks every shift, and oral care every six hours. The record also showed a care plan for tube feeding related to dysphagia and interventions for G-tube care every shift and local care to the G-tube site as ordered. Facility records did not show an order for gastrostomy tube placement verification before starting enteral feeding or for site care every shift. Review of the MARs/TARs from August 2025 through June 2026 did not reveal documentation that G-tube site care was provided every shift or that residual feeding was checked and the amount recorded. The ordered four-hour water flushes were not always documented as 150 mL, and there were two separate areas for staff to document the amount of feeding infused, with entries that did not consistently match the ordered amount or each other. Nursing progress notes sometimes stated that tube placement was confirmed by air auscultation, feeding was infusing without difficulty, no residual was noted, and the G-tube site had no signs or symptoms of infection, but these notes were not present for every shift of every day.
Delayed G-tube Feeding Administration
Penalty
Summary
The facility failed to ensure a resident with a gastrostomy tube received enteral feeding at the physician-ordered time. Resident #42, a male with athetoid cerebral palsy, muscle wasting and atrophy, and gastrostomy status, was assessed as severely cognitively impaired and dependent on staff for all nourishment and hydration. His care plan and order summary directed Jevity 1.5 at 85 mL/hr with water at 68 mL/hr via pump from 3:00 PM to 6:00 AM, and he was also documented as NPO and at risk for dehydration related to PEG feedings. On observation, the resident’s feeding pump was found next to the bed and turned off at 3:07 PM while he was not in his room. At 4:16 PM, after he returned from the Day Center, the pump was still off. At 4:42 PM, an LVN was observed changing the g-tube dressing and then hooking the resident up to his feeding. Staff interviews indicated the resident often returned from the Day Center after the ordered start time, and the DON and ADM stated he was not connected at 3:00 PM because of his late return. The ADM stated the resident was not receiving the full 15 hours of formula and hydration as ordered, and the DON stated staff were trained to follow physician orders for g-tube nutrition.
Resident with G-tube was fed while lying flat
Penalty
Summary
A deficiency was cited after a resident with a G-tube was observed lying in bed supine and halfway down the bed while enteral feeding was running. The resident’s head was against the back rest of the bed with the neck bent forward, and the resident was positioned at less than 30 degrees during the feeding. A CNA stated the resident was lying lower than she should have been while the tube feeding was running and said the feeding should be turned off when the resident needs repositioning. During the same observation, an LVN assessed the resident and stated the resident should not be lying supine while enteral feeding was being delivered. The LVN paused the tube feeding and said additional assistance was needed to safely elevate the resident from the supine position, adding that the feeding should not be on when the resident was lying flat because it can lead to aspiration and choking. The DON later stated the resident’s head should be elevated above 30 to 45 degrees to prevent aspiration and that the resident should never be lying flat. The facility policy titled Gastrostomy Tube Care and Management stated that before every feeding the tube position should be verified and, if feeding is continuous, the position should be checked every shift and as needed.
Failure to Verify G-Tube Placement Before Medications and Water Administration
Penalty
Summary
The facility failed to follow its policy for verifying gastrostomy tube placement before administering medications and water to a resident with a PEG tube. R6 was admitted in February 2026 with diagnoses including oropharyngeal dysphagia, severe physical deconditioning, and cognitive impairment. Her accepted quarterly MDS assessment identified moderate cognitive impairment, dependence on staff for all ADLs, impairment of upper and lower extremities, wheelchair use, and receipt of 51% or more of total calories and 501 cc or more of fluids daily through the feeding tube. R6’s care plan identified her as at risk for impaired nutritional status related to G-tube feedings and directed staff to keep her upright during and after feedings, flush the tube with water before and after feedings or medication administration, and notify the provider for tube dislodgement or patency concerns. Her physician orders included Isosource tube feeding and scheduled free water flushes through the PEG tube. During observation, an LPN prepared crushed medications and administered them through the G-tube without routinely checking placement first. He elevated the head of the bed, inserted a syringe into the tube, opened the stopcock to let air escape, and administered water and medications by gravity. During interview, the LPN stated he did not routinely check G-tube placement before giving medications or water and believed it was not needed because the tube had previously been verified by x-ray when changed. He also was unsure about the small amount of liquid noted at the tube site during administration. The RN stated she did not think placement still needed to be checked and would need to review the policy, while the DON stated she thought there was a provider order exempting R6 from placement checks, but no such order was found. The facility policy required checking proper placement of the G-tube prior to medication administration and documenting verification of tube placement.
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