Katherine Luther Residential Health Care and Rehabilitation Center

Deficiency Details, Complaint Survey, May 23, 2011

PFI: 0604
Regional Office: Central New York Regional Office

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F322 483.25(g)(2): PROPER CARE & SERVICES FOR RESIDENT W/ NASO-GASTRIC TUBE

Scope: Pattern

Severity: Immediate Jeopardy

Substandard Quality of Care

Corrected Date: July 1, 2011

Based on the comprehensive assessment of a resident, the facility must ensure that a resident who is fed by a naso-gastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers and to restore, if possible, normal eating skills.

Citation date: May 23, 2011

Based on observations, record reviews, staff interviews conducted during the partially extended abbreviated survey (NY00101105), it was determined the facility failed to have a system in place to ensure appropriate treatment and services were provided to the 6 residents (Residents #1, 2, 3, 4, 5 and, 6) in the facility fed by a gastrostomy tube (G-tube, feeding tube inserted through the abdominal wall). Specifically, Resident #1 required hospitalization for peritonitis (severe infection within the abdomen) due to dislodgement of the G-tube and subsequently expired. For Residents #1, 3 and 5, the interdisciplinary team did not assess and implement interventions to prevent the repeated need for reinsertion of their G-tubes. Resident #2's G-tube was replaced with sizes not ordered by the physician. Additionally, the facility failed to ensure the RNs and LPNs were trained and able to demonstrate competency, regarding the insertion of G-tubes and/or the safe administration of tube feedings for Residents #1, 2, 3, 4, 5, and 6. The facility did not ensure their policies and procedures for feeding tube insertion and the safe administration of tube feeding formula were consistently implemented to ensure they met accepted standards of quality. This resulted in actual harm that was Immediate Jeopardy and Substandard Quality of Care to Resident #1's health and safety; and the potential for serious harm that was Immediate Jeopardy and Substandard Quality of Care for R esidents' #2, 3, 4, 5 and 6.
Findings include:

The facility policy, Replacement/Insertion of Gastrostomy Tube, revised January 12, 2011, documented that after the insertion of a G-tube, the licensed nurse was to determine proper placement of the G-tube within the resident's stomach, by instilling 5 cc (cubic centimeters) to 10 cc of air through the tube, while auscultating (listening with a stethoscope) the resident's stomach, listening for a "whooshing" sound. Staff were to "notify (the) physician" if there was any "bleeding or abdominal distention." The policy specified that G-tube replacement should be done every 3 months and PRN (as needed) when the tube became "degraded or faulty in usage." The policy documented "if the G-tube has been in less that one month, DO NOT attempt to re-insert, call MD immediately." The policy did not document to aspirate the resident's stomach contents after the G-tube was replaced/inserted.

The facility policy, Gastrostomy Tube Feeding, Bolus Method (specific amount given at one time), revised January 12, 2011, documented that prior to administering a tube feeding, a licensed nurse was to check the position of the G-tube (for accuracy) by aspirating (withdrawing with a syringe) the G-tube for gastric (stomach) contents. The policy documented "if tube becomes dislodged, notify MD."

1) Resident #1 had diagnoses including dementia, esophageal reflux, and had a G-tube. The resident's most recent Minimum Data Set (MDS) assessment, dated May 6, 2011, documented the resident had severe cognitive impairment; required extensive to total assistance with all activities of daily living; and had a feeding tube.

Nursing progress notes, written by LPN #1 on October 3, 2010 at 10:38 AM, October 14, 2010 at 4:12 AM, and on January 13, 2011 at 2:45 AM, documented that prior to administering the resident's tube feedings, she checked the G-tube for correct placement by hearing "air in the stomach." There was no documentation that LPN #1 aspirated gastric contents to check for accurate placement of the G-tube, as specified in the facility's policy.

The comprehensive care plan (CCP), dated March 9, 2011, documented the resident relied on tube feedings to meet her nutrition/hydration needs. Approaches included monitoring the resident for tolerance to the tube feeding; monitoring for signs/symptoms of infection/aspiration (inhalation of stomach contents); and placement of an abdominal binder over the G-tube site, to prevent the resident from pulling it out; "If out- replace." The current CCP, "reviewed (by the interdisciplinary team) March 17, 2011" did not address interventions to prevent the resident's repeated removal of the G-tube.

Physician's order, dated March 24, 2011, documented the resident's PEG (percutaneous endoscopic G-tube)...to be changed every 3 months; the next PEG change was due on April 13, 2011.

The physician's most recent progress note was dated March 24, 2011 and documented "episodically she (the resident) pulls the PEG out and then staff is able to put it back with no major trouble."

Nursing progress notes documented nursing staff reinserted the resident's G-tube 14 times between October 2, 2010 and April 29, 2011, including:
- on October 15, RN #2, Coordinator of Staff Development, checked the G-tube placement by "injection of 60 ml (milliliters) air". (The facility policy documented instilling 5 cc to 10 cc of air through the tube).
- on January 12, 2011 at 8:16 PM, the nursing note documented the resident's G-tube became dislodged; the "nursing supervisor and MD were notified"; and the nursing supervisor replaced it with an "18 french 20 ml PEG tube. PEG site presented with a small amount of herniated tissue; a scant amount of frank blood. Resident complained of moderate pain during the replacement procedure, otherwise tolerated well." The documentation was unclear whether the physician was notified of the resident's herniated tissue, abdominal pain and frank blood present.

On April 7, 2011, the physician ordered the resident's tube feeding formula changed from Jevity 1.2 Cal (tube feeding formula) to Jevity 1.5 Cal for 5 cans a day, bolus feeding; with water flushes before and after feedings and medications; and specified "If tube becomes dislodged, notify the physician."

On May 5, 2011, RN Supervisor #1's progress note at 10:48 PM, documented a certified nurse aide (CNA) noticed the resident's G-tube lying in the resident's bed with the balloon (filled with water to prevent the tube from coming out) intact. "New PEG tube inserted without difficulty." The note did not specify how, or if, the nurse verified placement of the G-tube within the resident's stomach.
- On May 5, 2011 at 10:48 PM, RN Supervisor #1 documented a "late entry" that specified "placement of resident's PEG tube replacement checked with this writer and charge nurse after insertion on 5/5/11 evening."

The next nursing progress note was dated May 6, 2011 at 1:27 PM by the LPN. The LPN documented the resident had "abdominal distention with pain when touched. Vomited a moderate amount". The note specified the physician was called, and the resident was sent to the hospital at 11:00 AM that day.

The facility Patient Transfer Form, dated May 6, 2011, documented the resident was transferred to the hospital due to "distention of abdomen on right side, complaints of pain when touched. Last tube feeding done at 6 AM. Vomited mod(erate) amount of yellow emesis. Tube replaced on 3-11 (shift) on May 5, 2011."

The hospital physician's Emergency Provider Record, dated May 6, 2011, documented:
- the resident was evaluated at 11:59 AM for complaints of constant, dull, abdominal pain;
- the resident's abdomen was distended;
- an abdominal CT scan was abnormal;
- the physician's clinical impression was abdominal pain related to intestinal perforation after G-tube placement;
- the resident was admitted to the hospital at 3:21 PM on May 6, 2011; and
- the resident's G-tube was removed at 6:30 PM on May 6, 2011.

The CT (radiological test) of the resident's abdomen and pelvis, dated May 6, 2011 at 2:18 PM, documented free air in the abdomen, and a G-tube projecting over the left abdomen. "It is not entirely clear that this tube is in the stomach. It may be next to the stomach in the abdominal fat."

A nursing note, written by a hospital emergency department RN on May 6, 2011 at 4:14 PM, documented she called the facility about an issue with the resident's G-tube, and was told that after the resident pulled out the G-tube, it was replaced by the nursing supervisor during the evening shift on May 5, 2010.

Verbal physician's hospital admission orders, dated 4:55 PM on May 6, 2011, documented the resident's diagnosis was "dislodgement (of) G-tube."

The hospital admission and physical examination, dated May 6, 2011, documented the resident's G-tube came out on May 5, 2011, and was reinserted. "Today her abdomen was distended. She has been admitted with peritonitis."

The hospital attending physician's discharge summary, dated May 8, 2011, documented the resident continued to deteriorate, and expired that date from septic shock, secondary to peritonitis.

The hospital final principal diagnosis was "Mechanical complication of gastrostomy, present on admission." Secondary diagnoses, also present on admission, included peritonitis, severe sepsis, and septic shock.

The facility Investigation Report of Accident with Injury, signed (not dated) by the Assistant Administrator, and provided to the surveyor on May 23, 2011, documented the resident's G-tube was found out on May 5, 2011; was reinserted; and its placement was checked. The resident was sent to the hospital due to abdominal distention, pain upon palpation, and vomiting. The resident developed peritonitis and expired May 8, 2011 at 2 AM.

Three employee statements included in the facility's investigation report included:
- a personal statement, dated May 10, 2011, by RN Supervisor #1 (who reinserted the resident's G-tube on May 5, 2011), documented "placement was checked after insertion. There were 4 other people in the room. This was all done about 10:30 PM." There was no documentation how the G-tube's placement was "checked".
- a personal statement, by LPN #2 on May 11, 2011, documented she was in the room when the resident's G-tube was replaced, placement verified, and air instilled in the tube. "The sound was so loud everyone in the room could hear it. I said I can hear correct placement without the stethoscope!"
- a personal statement, dated May 11, 2011 by LPN #1 (who administered the resident's 6:00 AM tube feeding on May 6, 2011), documented she checked the G-tube for placement, "which was confirmed." There was no documentation how the G-tube's placement was "confirmed".
The "Summary of Investigation Outcome" was blank; the report did not include signatures of the Director of Nurses (DON) or the Administrator.

At 3:15 PM on May 23, 2011, a surveyor interviewed RN #2, the Coordinator of Staff development, regarding staff training and demonstration of competency to insert G-tubes and administer tube feedings. RN #2 stated the facility did not provide nurses with specific training to replace G-tubes, and they were not required to demonstrate competency to perform the procedure. RN #2 stated that if a nurse was uncomfortable with replacing a G-tube, he or she would be observed by a nurse manager, supervisor, or Coordinator of Staff Development. He stated, "This is within the scope of practice for RNs and LPNs." Regarding verification of placement of the G-tube within the stomach, RN #2 stated the procedure was to inject air into the G-tube with a syringe, and listen for a gurgle in the stomach. He stated aspiration of stomach contents was not required, as this is not in the facility policy.

A surveyor interviewed RN Supervisor #1 at 3:35 PM on May 23, 2011 who stated she replaced the resident's G-tube on May 5, 2011. RN Supervisor #1 stated G-tubes were discussed during general orientation when she began employment at the facility 7 years ago. She stated she was not required to demonstrate competency for G-tube insertion. When asked how she checked for placement of the G-tube within the resident's stomach at the time of insertion on May 5, 2011, RN Supervisor #1 stated she injected 60 cc of air and listened over the resident's stomach with a stethoscope. She stated she needed to push the plunger of the syringe with enough force to hear the "swish" of air in the resident's stomach. She stated had replaced Resident #1's tube 2 to 3 times before and had "to move" it "to the left when inserting." When asked if she the resident for stomach contents, RN Supervisor #1 stated she did not aspirate, as it was not the facility policy.

At 3:50 PM on May 24, 2011, a surveyor interviewed LPN #2, who was present on the evening of May 5, 2011 when RN Supervisor #1 replaced the resident's G-tube. LPN #2 stated she was standing next to the resident's bed, and could hear the air when it was injected into the G-tube. LPN #2 stated she had no formal training to insert a G-tube, and had never inserted one. She stated she watched RN Supervisor #1 insert several G-tubes, and RN Supervisor #1 told her she would know how to insert one, if needed, since she observed this procedure.

At 3:55 PM on May 24, 2011, a surveyor interviewed a CNA who stated she was standing at the foot of the resident's bed when RN Supervisor #1 inserted her G-tube on the evening of May 5, 2011. The CNA stated that when the RN Supervisor #1 inserted air into the resident's G-tube, she heard a sound like air coming out of a balloon.

A surveyor interviewed LPN #1 via telephone at 9:30 PM on May 24, 2011, regarding her administration of a tube feeding to the resident at 6:00 AM on May 6, 2011. She stated she inserted air into the G-tube to check for placement within the resident's stomach. LPN #1 stated she did not aspirate the resident's stomach contents prior to administration of the tube feeding, and "never" did so. LPN #1 stated she had been employed by the facility for 20 years, and did not recall if she was trained to insert G-tubes and administer tube feedings; and was unsure if she was required to demonstrate competency to perform these procedures.

On May 25, 2011, review of nursing staff's personnel and training records revealed:
- RN Supervisor #1 was hired as a Nursing Supervisor on August 16, 2004. The "Nurse Skills Verification Checklist," dated August 18, 2004, documented initials of a "mentor", dated August 2008, for tube feeding-related skills including "continuous/pump, bolus feed, and gravity feed." The skill of "Replacement/Insertion of Gastrostomy Tube" was marked, N/A (not applicable).
- RN #2 (Coordinator of Staff Development) was hired on October 6, 2009; the personnel file contained no documented evidence of training/demonstration of competency to insert a G-tube and administer tube feedings.
- LPN #1's personnel file contained no documented evidence of training/demonstration of competency to insert a G-tube and administer tube feedings.

During an interview with RN #2 at 9:30 AM on May 25, 2011, he stated the facility had no records of staff training for staff hired prior to 2004. He stated a search of computer records showed no documented evidence of staff training and/or demonstration of competency to insert G-tubes and safely administer tube feedings.

The hospital radiologist was interviewed via telephone on May 25, 2011 at 8:30 AM. He stated he remembered the resident well, and was worried that her G-tube was not in the proper position when she was hospitalized on May 6, 2011. The radiologist stated that feeding tubes fell out or were pulled out in nursing home residents frequently. He stated that when a resident resided in a nursing home, and radiologic images were not available, stomach contents must be aspirated to verify proper placement. The radiologist stated that injecting 60 cc of air into a feeding tube that was not in proper position would be a problem. He stated that administration of a feeding without verifying placement could be worse than the damage caused by injecting 60 cc of air.

In summary, the facility failed to protect Resident #1's health and safety, as she developed peritonitis, severe sepsis, and septic shock related to the re-insertion of the G-tube and the subsequent administration of a tube feeding, without determining the proper location of the resident's G-tube, as stated in the facility policy. The facility:
- failed to ensure RNs and LPNs were trained and demonstrated competency to insert G-tubes and administer tube feedings safely;
- failed to ensure the interdisciplinary team assessed the resident and developed effective interventions related to her repeated removal of the G-tube; and
- the facility failed to ensure policies and procedures were consistently implemented for feeding tube insertion and the safe administration of the tube feeding formula.

2) Resident #5 had diagnoses including a progressive neurological disease, dysphagia (difficulty swallowing), and had a G-tube.

Nursing progress notes documented, between August 5, 2010 and February 18, 2011, nursing staff (including LPN #4, RN #4 and #5) reinserted the resident's G-tube 11 times.

The annual Minimum Data Set (MDS) assessment, dated March 29, 2011, documented the resident had severe cognitive impairment; required extensive to total assistance for all activities of daily living; and received her calories and fluids via feeding tube daily.

The comprehensive care plan (CCP), dated April 12, 2011, documented the resident had excessive spastic movements, and received all nourishment and fluids via G-tube. There was no documentation on the CCP that effective interventions were developed regarding her repeated removal of the G-tube. The CCP did not address the resident's potential for injury related to removal of the G-tube with the balloon inflated.

A nursing progress note, dated April 25, 2011 at 7:36 PM, documented that after the resident pulled out the G-tube, an RN (name not documented) replaced the G-tube.

A nursing progress note, dated May 7, 2011 at 11:45 AM, documented a small amount of bleeding at the site of insertion when the resident pulled out her G-tube. RN #3 replaced the tube and identified correct placement by auscultation (listening over the abdomen while injecting air into the G-tube).

A nurse practitioner (NP) monthly note, dated May 10, 2011, documented the resident exhibited "thrashing and constant movement," and "This past month she has pulled out her Foley (urinary catheter) and feeding tube numerous times."

The resident's most recent physician's orders, dated May 20, 2011, documented the resident received a tube feeding of 2 Cal HN (brand of feeding) at 55 cc/hour, for 22 hours/day. The resident's G-tube was to be changed every 3 months.

A nursing progress note, dated May 20, 2011 at 7:00 PM, documented the nursing supervisor, (RN #7) was called after the resident pulled out her G-tube. When replacing the tube, the "procedure resulted with immediate gastric return, position verified with injection of 20 ml (milliliters) of air via syringe down PEG tube."

On May 23, 2011 at 3:30 PM, a surveyor interviewed RN #7 regarding her training to insert G-tubes. She stated she was not trained to insert G-tubes prior to her employment at the facility in September 2010. RN #7 stated that RN #2 showed her how to replace the G-tubes of Residents #1 and 3. She stated she verified placement of the G-tube within the stomach by injecting 20 ml of air and listening for a "swoosh." RN #7 stated she did not verify placement by aspirating stomach contents.

During an interview with RN #3 at 2:00 PM on May 24, 2011, she stated she "was shown a policy at general orientation" on G-tube replacements, when she was hired 2 1/2 years ago. She stated she did not receive "hands-on training" before she began inserting G-tubes herself; and was not required to demonstrate competency to perform the procedure. RN #3 stated she was told to determine proper G-tube placement by auscultating over the stomach while injecting 10 cc of air. She said she was not told to aspirate the resident's stomach contents prior to feeding, as specified in the G-tube Feeding Bolus Method policy.

At 3:00 PM on May 24, 2011, a surveyor interviewed RN #6 regarding insertion of G-tubes. She stated she could not remember if she was ever trained or required to demonstrate competency to insert G-tubes. She stated she determined proper placement of the G-tube within the stomach by injecting 10 cc of air through the tube and auscultating over the stomach. RN #6 stated she "occasionally aspirated" stomach contents to check placement.

At 3:20 PM on May 24, 2011, a surveyor interviewed LPN #4 regarding G-tube insertion. He stated he was employed by the facility as an LPN since November 2007. He stated he did not receive training to insert G-tubes, and did not demonstrate competency to perform the procedure. LPN #4 stated he "went over the procedure" with RN #5, a former charge nurse. He stated he verified placement of the G-tube by injecting 10 cc of air through the tube and auscultating over the stomach. LPN #4 stated he used no other method to check placement.

Review of LPN #4's Nurse Skills Verification Checklist revealed his skill to administer a gravity (without pump or syringe) tube feeding was verified on October 1, 2007. His skill to administer continuous/pump feedings was not verified, and the skill for Replacement/Insertion of Gastrostomy tube was blank.

At 9:10 AM on May 25, 2011, a surveyor interviewed RN #4 regarding G-tube insertion. She stated she did not remember receiving training to insert G-tubes, and was not asked to demonstrate competency to perform the procedure. She stated she could call another nurse if she needed help. RN #4 stated she verified placement of a G-tube by auscultating while injecting the tube with 30 cc of air. She stated that she did not check placement by aspirating stomach contents.

In summary, the facility failed to protect the health and safety of Resident #5, as:
- RNs and LPNs did not receive training and were not required to demonstrate competency to insert G-tubes and administer tube feedings safely;
- policies and procedures for feeding tube insertion and maintenance were not consistently implemented and evaluated to ensure they met accepted standards of quality; and
- the interdisciplinary team did not assess the resident and implement interventions for the potential for injury related to her ability to repeatedly remove the G-tube.

3) Resident #2 had diagnoses including Alzheimer's disease, dysphagia (difficulty swallowing), and had a G-tube.

The resident's physician's orders, dated November 28, 2010, documented a bolus (amount given at one time) feeding of 1 can of 2 Cal HN (brand of tube feeding) was to be administered daily at 10:00 PM, with administration of 75 cc of water before and after the feeding; staff were to flush the G-tube with 150 cc of water every shift; the resident was to have a size #10 G-tube, to be changed every 3 months (due December 22, 2010).

A nursing progress note, written by LPN #3 at 1:41 PM on December 19, 2010, documented the resident's G-tube was found on his lap, and LPN #3 inserted a size #20 Foley (catheter) for a replacement G-tube.

A nursing progress note, written by LPN #3 at 12:20 PM on December 20, 2010, documented a "new PEG tube place" with a size "#14 placed; uneventful."

A nursing progress note, written by LPN #6 at 4:14 AM on December 21, 2010, documented the resident's "new PEG (percutaneous endoscopic G-tube) looks smaller in diameter and appears to be working its way back out." There was no documented progress note that an RN assessed the resident's G-tube placement and no documentation the physician was notified.

Physician's orders, dated March 29, 2011, documented the resident's size #10 G-tube was to be changed every 3 months (due March 20, 2011); the resident was to receive a bolus feeding of 2 Cal HN daily at 10:00 PM; and staff were to administer 100 cc of water before and after the feeding, and 200 cc of water at 10:00 AM and 4:00 PM.

The March 2011 treatment administration record (TAR) documented the resident's G-tube was size #10, and was changed on March 28, 2011. The April 2011 TAR documented the size #10 G-tube was due to be changed on June 28, 2011.

The resident's most recent Minimum Data Set (MDS) assessment, dated April 13, 2011, documented the resident had severe cognitive impairment and received 25% or fewer calories, and 501 cc or more fluids, via feeding tube daily.

The comprehensive care plan (CCP), dated April 27, 2011, documented the resident received G-tube feeding to provide additional calories and fluids. The CCP did not specify the size of the resident's ordered G-tube.

On April 29, 2011, the physician wrote an order to discontinue the resident's 10:00 PM tube bolus feeding, and continue to flush his G-tube with 200 cc of water BID (twice daily).

The resident's May 2011 TAR documented the resident's size #10 PEG tube was due to be changed on June 28, 2011.

At 1:00 PM on May 23, 2011, a surveyor interviewed LPN #3, who stated she was employed by the facility for 14 years. She stated the protocol was to change G-tubes every 3 months, and "could be done by any nurse on any shift". LPN #3 stated that after inserting a G-tube, she determined correct placement by listening with a stethoscope over the G-tube insertion site while injecting 5 to 10 cc of air into the G-tube. She stated she did not aspirate stomach contents to verify correct placement of the G-tube. LPN #3 said she could not remember when she demonstrated competency to insert a resident's G-tube.

Review of LPN #3's personnel file at 4:00 PM on May 23, 2011, revealed no documented evidence of training and demonstration of competency to insert G-tubes. The training records documented the LPN was assessed for providing a bolus tube feeding in October 1997.

At 2:00 PM on May 24, 2011, a surveyor interviewed RN #3, the charge nurse on the resident's unit, about the size of the resident's G-tube. She stated she did not know why the resident had a size #14 G-tube, when a size #10 was ordered by the physician. She stated, "Maybe the correct size was unavailable."

At 5:10 PM on May 24, 2011, a surveyor observed the resident when LPN #7 checked the size of the resident's G-tube. The LPN stated it was size #14. When interviewed about the size of the G-tube, LPN #3 stated it should be the size ordered by the physician.

At 12:05 PM on May 25, 2011, a surveyor interviewed the Director of Nursing (DON) about the resident's G-tube, ordered to be size #10. She stated she did not know why the resident's G-tube was replaced with sizes #20 and 14 in December 2011, and why the resident currently had a size #14 G-tube. The DON stated the resident should have the G-tube size that was ordered by the physician.

In summary, the facility failed to protect the health and safety of Resident #2, as:
- the resident's G-tube was replaced with sizes that were not ordered by the physician;
- RNs and LPNs did not receive training and were not required to demonstrate competency to insert G-tubes and administer tube feedings safely; and
- policies and procedures for feeding tube insertion and safe tube feeding administration were not consistently implemented and evaluated to ensure they met accepted standards of quality.

ADDITIONAL PERTINENT STAFF INTERVIEWS:
- At 9:25 AM on May 25, 2011, a surveyor interviewed LPN #5, the charge nurse on the unit where Residents #3, 4, and 5 resided. She stated she had not inserted a G-tube prior to her employment at the facility, and inserted her first G-tube alone after observing another nurse insert one. LPN #5 stated that when inserting a G-tube, she checked for proper placement by inserting 30 cc of air into the G-tube with a syringe, then removing the piston and listening for a "burp" of air to come from the stomach. She stated she used the same method to check for correct G-tube placement prior to administering a tube feeding.

- At 3:30 PM on May 24, 2011, a surveyor interviewed the Medical Director via telephone regarding facility policies and procedures for G-tube insertion and tube feeding. He stated he would expect the facility to train nurses and have them demonstrate competency to perform these procedures.

10NYCRR 415.12(g)(2)

F490 483.75: FACILITY ADMINISTERED EFFECTIVELY TO OBTAIN HIGHEST PRACTICABLE WELL BEING

Scope: Pattern

Severity: Immediate Jeopardy

Corrected Date: July 1, 2011

A facility must be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

Citation date: May 23, 2011

Based on observations, record reviews, and staff interviews conducted during the partially extended abbreviated survey (NY00101105), it was determined the facility's administration (including Administrators and the Director of Nurses) failed to administer the facility in a manner that protected the health and safety of its 6 tube fed residents (Residents #1, 2, 3, 4, 5, and 6). Specifically, the facility's administration failed to have a system in place to ensure Residents #1-6 who were fed via gastrostomy tube (G-tube, inserted through the abdominal wall), received appropriate treatment and services in accordance with accepted professional standards. This resulted in actual harm for Resident #1 and the potential for serious harm for Residents #2, 3, 4, 5 and 6 that is Immediate Jeopardy.
Findings include:

F322 - Gastrostomy tube feeding - the facility's administration, including the Administrator and the Director of Nurses (DON):
- failed to have a system in place to ensure nursing staff received formalized training and were required to demonstrate competency to safely insert G-tubes and administer tube feedings, flushes, and medications.
- failed to have a system in place to ensure consistent implementation of policies and procedures that met accepted professional standards of quality related to services provided to residents with G-tubes.
- failed to have a system in place to ensure assessment and implementation of interventions for the potential for injury related to repeated removal and reinsertion of G-tubes (Residents #1, 3 and 5).
- failed to have a system in place to ensure the physician ordered G-tube size was inserted into Resident #2.

At 11:00 AM on May 25, 2011, a surveyor interviewed the Assistant Administrator/Director of Quality Assurance (QA). She stated:
- within the past year, the facility did not conduct QA monitoring or topic reviews related to G-tube insertion by nurses and tube feeding administration procedures.
- staff should be trained and required to demonstrate competency to insert G-tubes and administer tube feedings. She stated there was "no training going on for the last couple of years because the inservice person was running the CNA (certified nurse aide) training classes."
- she was unaware nurses utilized multiple methods of verifying G-tube placement when inserting G-tubes and administering tube feedings, and did not aspirate stomach contents prior to administering tube feedings per policy.
- there were no audits/monitoring of staff compliance regarding the consistent implementation of facility policies.
- Resident #1 expired following the G-tube insertion by a facility RN Supervisor on May 5, 2011. There was no additional investigation, other than nurse interviews, and no revisions were made to the facility's policies or procedures.

At 12:00 PM on May 23, 2011, a surveyor interviewed the Director of Nurses (DON) regarding facility policies and procedures for staff training and demonstration of competency to insert G-tubes and administer tube feedings. She stated that for newly hired nurses, there was no policy to train them to insert G-tubes, or to demonstrate competency to perform these procedures. During orientation, a nurse would verbally describe to a mentor the steps to perform these procedures. Competency would later be demonstrated with a resident with a G-tube. The DON stated the facility had no formal documentation of staff training/demonstration of competency to insert G-tubes, or to administer tube feedings. She stated this would be documented in the nursing progress notes of specific residents. When re-interviewed at 9:40 AM on May 25, 2011, the DON stated nurses could aspirate stomach contents to check for proper placement of a G-tube, "but the facility does not expect them to do that. Nurses are to follow the facility policy to inject air only." When asked how nurses were to check for proper G-tube placement prior to administering a tube feeding, the DON stated they were to insert air only, and were not required to aspirate stomach contents.

At 11:20 AM on May 25, 2011, a surveyor interviewed the Administrator. He stated:
- RN #1 and LPN #1 were interviewed, and said they followed facility procedures correctly for G-tube insertion and tube feeding administration, respectively. He stated the nurses were not questioned to determine if they followed the specific components of the procedures.
- his role in QA is to attend quarterly meetings and present issues identified in the Plan of Correction from the most recent standard facility survey. The most recent quarterly QA meeting was in April 2011. There has been no data tracking/monitoring of problems with G-tube insertion and administration of tube feedings.
- after May 9, 2011, the facility did not evaluate other facility residents with G-tubes for the potential for problems related to G-tube insertion and tube feeding administration.

10NYCRR 415.26