Valley View Manor Nursing Home

Based on observations, staff interviews, and record review, conducted during an abbreviated survey (#NY00093158) it was was determined for 1 of 4 residents reviewed for feeding tubes (Resident #1) the facility did not ensure services provided met professional stands of practice. Specifically, licensed practical nurses (LPN) replaced the resident's jejunostomy tube (J-tube, a feeding tube inserted into the small intestine), per the facility's policy. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #1 has diagnoses which include mental retardation, quadriplegia, psychosis, aphasia, and dysphagia (difficulty swallowing).

The Minimum Data Set dated November 2, 2010 documented the resident required total assistance for eating. The summary score area for cognition was blank.

The comprehensive care plan dated August 18, 2010 documented the resident required a feeding tube because of her dysphagia.

The physician's orders dated October 7, 2010 documented to discontinue "G-tube, J-tube change."

The nurse practitioner's (NP) telephone order dated October 23, 2010 documented "may re-insert J-tube" 22 French (size of tube) with a 3 cubic centimeter balloon.

The LPN note dated October 23, 2010 documented the resident pulled out her J-tube. The NP was notified and and gave an order to re-insert the J-tube. This note recorded the J-tube was re-inserted per the facility's policy, checked for placement, and that the resident tolerated the procedure well.

The facility's current policy "Replacement of Gastrostomy/Foley tubes for Enteral feeding" dated September 1, 2010, documented replacement of J-tubes may be done by a physician, or when it is necessary, by a licensed nurse who is familiar with the procedure.

In an interview with the Director of Nursing (DON) on December 8, 2010 at 2:50 PM she stated licensed nurses could replace J-tubes if they were familiar with the procedure. Who ever had done the procedure before and felt confident with doing so could change J-tubes. She stated they define a licensed nurse as either a registered nurse or an LPN. The DON said if a licensed nurse had not re-inserted a J-tube before, they would receive training at the facility.

In an interview on December 8, 2010 at 3 PM with the LPN who re-inserted the J-tube, she stated the resident's J-tube came out at the change of shift (day to evening). The LPN notified her supervisor who told her there was a policy in place for changing/replacing J-tubes. The LPN said she read the policy then called the nurse practitioner (NP). The LPN stated the NP asked her if she was confident replacing the tube and she said yes. She stated she observed/assisted another LPN in the past with re-placing the resident's J-tube, and that was how she learned to do the procedure. The LPN said that was the first time she did this "solo", and that it went well. She checked for placement with insertion of air, and then flushed the tube. The LPN stated the feeding infused fine.

In an interview with the DON on January 5, 2011 at 10:45 AM she stated there had been no change to the enteral feeding tube policy, and that no additional residents had their feeding tube replaced/changed at the facility. She said Resident #1 was the only resident whose feeding tube had been replaced/changed there.

In an interview with the DON on January 5, 2011 at 12:30 PM she stated there had been no inservice, staff training, or competencies regarding changing any type of feeding tube (J-tube, g-tube).

The NP was no longer employed by the facility, and therefore not available for interview.

In summary, the facility did not ensure professional standards of practice were maintained when licensed nurses replaced J-tubes.