F0693

J

Failure to Monitor and Manage Tube Feeding Leading to Repeated Aspiration and Harm

New Castle, Delaware Survey Completed on 12-13-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to adequately assess, monitor, and manage tube feeding and fluid needs for a resident with a gastrostomy tube, and to intervene appropriately when repeated aspiration events occurred. The resident was admitted with a diagnosis of feeding tube (gastrostomy status) and had a care plan directing staff to administer tube feeding and hydration as ordered, maintain the head of bed elevation during and after feeding, and flush the tube with specified amounts of water before and after medications and feedings. Dietary progress notes documented that the resident’s weight was stable and overweight by standard, with tube feeding ordered as Nutren 1.5 at 70 mL/hr for 18 hours and free water flushes (FWF) of 65 mL/hr for 18 hours, providing 1890 calories and 1170 mL of water per day. However, review of the Medication Administration Record (MAR) showed that staff documented providing tube feeding and FWF volumes far in excess of the ordered daily amounts on multiple days, with recorded totals of tube feeding and water flushes that greatly exceeded the prescribed 1260 mL of tube feeding and 1170 mL of FWF in 24 hours.

The resident experienced multiple episodes of tube feeding formula oozing from the mouth and nares, along with respiratory compromise, that were documented in progress notes but were not followed by documented reassessment or adjustment of tube feeding orders by the dietitian or medical providers. On one occasion, the resident was found unresponsive with low oxygen saturation and tube feeding seen oozing from the mouth; CPR was initiated, suctioning was performed, and the resident was sent to the hospital. The resident was later readmitted with the same tube feeding and water flush rates, and a subsequent note indicated treatment for aspiration pneumonia. Later MAR entries again showed staff-documented tube feeding and FWF volumes that exceeded the ordered amounts. Another nursing note described the resident with labored breathing, crackles in both lungs, and milky secretions pooling from both nares and mouth, with suctioning performed and an order obtained to send the resident to the hospital via 911. A hospital history note documented concern for overfeeding and aspiration, with admission for septic shock, pneumonia, and urinary tract infection.

Despite these events, dietary notes continued to state that the resident’s weights were stable or that weight gain was being evaluated for accuracy, and that no nutritional interventions were needed at that time, even when a dietary note recorded a net weight gain of 22.6% over seven months. A later dietary progress note indicated that the resident remained NPO and continued on the prescribed tube feeding regimen, with concurrent water flushes providing a total of 2132 mL of fluid per day. Nursing progress notes in a subsequent month documented repeated observations of Nutren feed coming out of the resident’s mouth, coarse crackles bilaterally, dyspnea, and the need for frequent suctioning, with the NP initially instructing staff to monitor the resident. Another note described fluid from the mouth, crackles, and continued monitoring, followed by a note that the resident was aspirating from the mouth with shortness of breath and lung crackles, leading to a recommendation from the NP to send the resident to the hospital. Interviews with the NP and dietitians revealed that the NP documented the resident as tolerating tube feeding after aspiration incidents, that the dietitian was not notified of earlier aspiration events or the hospital note about overfeeding, and that the dietitian acknowledged an assessment of tube feeding and water flush rates should be conducted after aspiration incidents. The facility’s own enteral nutrition policy required the RDN to assess energy, protein, and fluid requirements, compare them to ordered formula and flushes, and monitor weight, labs, and physical symptoms, and required nursing to communicate changes such as vomiting and high residuals, but the documented care and communication did not reflect consistent adherence to these requirements for this resident.

The facility’s leadership, including the DON, Medical Director, NP, Regional Registered Dietitian, and facility dietitian, acknowledged in interview that the resident had chronic encephalopathy and aspirated off and on, and that dietary staff usually changed orders and tracked tube feeding, aspiration, and labs. However, the Medical Director responded to a question about tube feeding coming out of the resident’s nose by stating that people vomit when they are sick, and there was no documentation that the tube feeding regimen was reassessed or modified in response to the repeated documented episodes of tube feeding formula oozing from the resident’s mouth and nares, the excessive volumes recorded on the MAR, or the significant weight gain. The survey findings concluded that the facility failed to ensure that the resident was assessed and monitored for nutritional and fluid needs and failed to implement interventions when the resident aspirated tube feeding multiple times and gained a significant amount of weight, resulting in harm including cardiac arrest during an aspiration event and multiple hospitalizations after aspiration of tube feeding.

Removal Plan

• Transferred the affected resident to the hospital
• Assessed all tube-fed residents for tolerance, weights, and aspiration signs
• Registered Dietitian and clinical leadership reviewed tube-fed residents’ status
• Convened a QAPI meeting
• Provided education to the dietitian and nursing staff on the enteral feeding policy with completion
• Implemented a structured audit and monitoring process of MARs and progress notes to ensure ongoing compliance and early identification of tube feeding intolerance