Failure to Ensure Proper Connection of G-Tube During Continuous Enteral Feeding
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident receiving enteral nutrition via G-tube was properly connected to the feeding pump when the pump was turned on, resulting in tube feeding formula running onto the floor instead of being delivered to the resident. The resident was an adult female with diagnoses including type II diabetes, gastrostomy status, dysphagia (pharyngeal phase), muscle wasting/atrophy, and malignant neoplasm of the endometrium. Her comprehensive MDS showed she was dependent on staff for most ADLs, had a BIMS score of 00, and required a feeding tube for nutrition. Physician orders specified an NPO diet, continuous G-tube feeding with Diabetic Source 1.5 at 55 ml/hr for 22 hours per day with water flushes every 4 hours, and a scheduled daily downtime for the feeding. On the survey date, the resident’s care plan documented that she required tube feeding and was to remain free of side effects or complications, with interventions including following current feeding orders. Earlier that day, the resident was observed awake in bed with the enteral feeding pump running at 55 ml/hr, and from the surveyor’s vantage point there were no visible concerns at that time. Later, the resident’s responsible party (RP), who was visiting, discovered that the resident’s G-tube was not connected to the feeding pump and that formula was running onto the floor. The RP reported that the resident had not been fed for at least the past hour due to the G-tube not being connected when the pump was turned on, and provided a video showing the G-tube disconnected and clamped, with a puddle of formula on the floor while the pump was running. Subsequent observations and interviews confirmed the sequence of events leading to the deficiency. When the surveyor returned to the room, the G-tube had been reconnected and the pump was running at 55 ml/hr, but formula remained on the floor from the earlier spill. LVN A stated that she had turned off the pump between approximately 9:00 and 9:30 for the ordered downtime, flushed and clamped the tube, and then returned around 11:30 to restart the feeding but forgot to reconnect the G-tube before turning the pump back on. She attributed the error to being busy and called away to assist another resident. CNA B reported that around 12:20 she entered the room to provide care, noticed the G-tube was still clamped, and at the same time the family observed formula running from the pump onto the floor, after which LVN A was called in and reconnected the tube. The facility’s own policy on enteral tube feeding via continuous pump required ensuring equipment and devices were working properly, and staff interviews acknowledged that not reconnecting the G-tube to the pump could result in nutrition and hydration issues, confirming that the resident did not receive the ordered enteral feeding during the period when the pump was running but the tube was disconnected.
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