A resident with both a G-tube and a J-tube had tube feeding and medication orders that did not specify which tube to use, and the chart lacked orders for J-tube flushes and dressing changes. Staff documented and performed J-tube flushes and dressing changes at both tube sites based on report and SBAR information, while an LPN administered meds through the G-tube and feeding through the J-tube during observation.
Improper Head-of-Bed Positioning During G-Tube Feeding: A resident with Alzheimer's disease, dementia, malnutrition, and a g-tube was observed receiving continuous tube feeding while the head of the bed was positioned at about 10 degrees and later flat, despite care plan guidance and a physician order to keep the head of the bed elevated during feeding. Staff interviews confirmed the expected elevation during tube feeding.
Two residents with g-tubes had incomplete tube feeding care. Staff did not label the water flush bags, one resident was observed with the HOB not elevated enough during tube feeding, and one resident’s care plan did not address g-tube care. The residents had significant medical histories including malnutrition, dementia, COPD, and other chronic conditions, and the DON stated the HOB should be elevated 30 to 45 degrees and the flush bag should be labeled with key tube-feeding information.
A resident with dementia, prior stroke, and documented swallowing difficulties, who relied on a g-tube for more than half of their nutrition and fluids, did not receive ordered continuous Jevity 1.5 Cal tube feeding and scheduled water flushes. Observations showed the formula and water hanging at the bedside while the resident was seated in the hallway without the feeding attached, and later in bed with the feeding still not connected. Despite clear physician orders for 23-hour tube feeding at a set rate and water flushes every four hours, and facility policies requiring adherence to physician orders, the RN responsible did not restart the feeding when the resident was taken out of bed, resulting in the ordered g-tube regimen not being followed.
A resident with a PEG tube, dysphagia, and severe cognitive impairment had a physician order for Fiber Source HN 1.2 at 47 ml/hr, but observations showed Diabetisource AC 1.2 was being run instead. The care plan noted tube feeding was needed but did not include the prescribed formula. Nursing documentation did not identify the formula being administered, and an LPN confirmed the formula in use did not match the order.
Two residents receiving enteral nutrition experienced significant weight loss when staff failed to ensure proper tube feeding delivery and bolus administration. One resident with multiple comorbidities and severe cognitive impairment had orders for continuous Jevity via G-tube, but observations over several days showed that, despite the pump being set at the ordered rate, only small amounts of formula actually infused while large volumes remained in the bottles, and the resident’s weight declined. Another resident with chronic kidney disease, diabetes, and severe cognitive impairment had orders for Jevity bolus feedings after meals and at bedtime, yet surveyors repeatedly observed full or unopened formula bottles at the bedside, with no corresponding documentation on the MAR, and a CNA reported that an LPN did not administer a bolus during breakfast despite the LPN’s claim that it had been given.
A resident with a g-tube, dysphagia, weight loss, CP, and malnutrition had tube feeding orders for Glucerna 1.5 at 60 ml/hr with water flushes every 6 hours, but staff repeatedly found the pump set incorrectly for flush timing and duration. The resident was also observed lying flat while TF continued during personal care, and the TF was not held or stopped during repositioning. An LPN later stated the pump had been restarted without checking the ordered rate and duration, and the DON said staff were expected to follow the physician’s TF orders.
An LPN administered gabapentin through a resident’s PEG tube without first confirming tube placement by measuring tube length or checking pH of aspirated contents. The LPN aspirated tan fluid, flushed the tube, gave the medication, and restarted the feeding pump. The DON stated staff were expected to verify placement by aspiration, but the facility did not check pH and had no monitoring to ensure proper placement checks were done.
A resident with a g-tube, stroke, dysphagia, diabetes, and kidney disease did not receive appropriate tube feeding care. Staff observed the resident with the HOB almost flat during continuous tube feeding, and later in a Broda chair with the back flat. The tube feeding bag was also left unlabeled, with no formula, rate, or hang time documented, and the resident’s care plan did not address tube feeding care.
Incorrect g-tube flush during med pass. A resident with seizures, brain injury, and dysphagia had a g-tube and orders for multiple meds via tube plus 120 ml water flushes before and after meds. An LPN diluted each med, flushed 120 ml before administration, and then gave 120 ml after each med, while staff later stated the order was confusing and needed clarification.
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