F0693

G

Failure to Verify Nasogastric Tube Placement and Monitor Enteral Feeding

Brooklyn, New York Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident receiving enteral nutrition via a nasogastric (NG) tube received appropriate care and monitoring for complications, including verification of tube placement as required by facility policy and physician orders. The resident was an infant with prematurity, chronic respiratory failure, ventilator dependence, and NG-tube dependence, with severely impaired cognition. Facility policy required verification of tube placement before feedings and medication administration, including checking exit length in centimeters and aspirating gastric contents, and the resident’s care plan and physician orders specifically directed staff to check NG tube placement before and after medications and feedings. However, the Treatment Administration Record and Medication Administration Record from admission through the date of the incident contained no documented evidence that nursing staff verified NG tube placement at any time, despite standing orders to do so.

On the evening of the incident, video surveillance and staff interviews showed that a CNA entered the resident’s room and paused the feeding pump to provide care, noting that the dressing securing the NG tube was soiled and lifted. The CNA called an RN, who removed the soiled dressing and instructed the CNA to hold the NG tube at the resident’s nose while the RN left the room to obtain tape, leaving the NG tube stabilized only by the CNA. The RN then returned, applied new tape, assisted with the resident’s care, and resumed the feeding. The CNA reported that the RN did not use a syringe to aspirate stomach contents before restarting the feeding, and the RN acknowledged not calling another nurse for assistance and not verifying tube placement after the dressing change. The facility’s investigation later concluded that this dressing change, during which the NG tube was manipulated and not re-verified, was the only major manipulation that could have caused tube dislodgement.

Later that same evening, another RN, who was not assigned to the resident, responded to a feeding pump error and changed the feeding bottle and giving set. This RN stated they checked NG placement by aspirating gastric residual but did not check the external mark on the tube and did not document the verification because they were not the assigned nurse. Around this time, the resident developed tachypnea, tachycardia, fever, and respiratory distress, prompting involvement of multiple nurses, a respiratory therapist, and a nurse practitioner, and eventual transfer to the hospital. Hospital records documented that the resident was admitted with respiratory failure due to aspiration pneumonitis/pneumonia caused by a misplaced NG tube in the left lung, with imaging confirming malposition of the NG tube into the left mainstem bronchus. The facility’s investigation and leadership interviews acknowledged that the NG tube exit length had not been documented on the Enteral Tube Placement Form and that nurses were required, but failed, to consistently verify and document NG tube placement before feedings and medications, including after the dressing change on the night of the incident.

The Medical Director, Attending Physician, Clinical Manager RN, Senior Director of Pediatrics, and DON all confirmed in interviews that facility practice and physician orders required verification of NG tube placement by checking the external mark and aspirating gastric contents before feedings and medications, and that this verification should have been documented in the resident’s records. The Clinical Manager RN stated that it was not the facility’s practice to document NG placement checks on the Treatment Administration Record, despite the written orders. The Attending Physician noted that the measurement at the skin exit site should have been recorded on the Enteral Tube Placement Form but was not. The Senior Director of Pediatrics and DON both indicated that the NG tube could have been dislodged during the dressing change when the RN left the CNA holding the tube and did not verify placement before resuming the feeding. These combined failures to follow policy and orders for NG tube verification and documentation, particularly surrounding the dressing change and continuation of feeding without confirmed placement, led to the resident receiving enteral feeding through a malpositioned NG tube, resulting in respiratory failure and aspiration pneumonitis.