Other·March 15, 2023

§483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident- §483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. The facility failed to ensure one sampled resident (Patient A), who were fed by enteral means, received the appropriate treatment and services to prevent complications of the enteral feeding. * CNA 1 administered G-tube feeding to Patient A but erroneously connected the G-tube feeding to the saline (instillation) port of the resident's closed suction system (the closed suction system was connected to the resident's tracheostomy tube and provided direct access to the trachea and lungs). The G-tube feeding infused for approximately 30 minutes directly into the resident's lungs until CNA 1 had observed that white fluid was leaking around Patient A's tracheostomy stoma. Administering G-tube feedings is a nursing function that must be performed by a licensed and trained health care professional. As a result, Patient A was admitted to the PICU for aspiration pneumonia. Findings: On 1/18/23 at 1600 hours, a telephone interview was conducted with Family Member 1. Family Member 1 stated Patient A was being treated for aspiration pneumonia in the PICU because a CNA had mistakenly connected the resident's G-tube feeding to his tracheostomy tube on 1/6/23. Family Member 1 stated the CNA had no business touching her son's G-tube feeding. Family Member 1 stated Patient A was receiving antibiotics at the acute care hospital, but his condition was like a roller coaster, and he was still fighting the infection from the aspiration pneumonia. Closed medical record review for Patient A was initiated on 1/19/23. Patient A was admitted to the facility on 11/3/15. Review of the Physician H&P General dated 7/21/22, showed Patient A had a tracheostomy tube and was gastrostomy dependent. Review of Patient A's Patient Orders showed an order dated 9/22/22, to administer 270 ml/hour of Jevity 1.2 Cal (type of enteral feeding) tube feeding via the G-tube (for one hour) every four hours. Review of the MDS dated 12/28/22, showed Patient A was totally dependent on the staff for eating (including intake of nourishment through tube feeding). Review of the Nursing Narrative Note entry by RN 1 dated 1/6/23 at 2125 hours, showed at around 2000 hours, the CNAs were asked to check Patient A's weight. According to the CNAs, they did not disconnect the G-tube feeding when they weighed the resident. However, at 2045 hours, RN 1 was informed by LVN 1 that there was leaking coming out from Patient A's tracheostomy site and tubing. The note further showed LVN 1 observed the G-tube feeding was mistakenly connected to the resident's closed suction system and Patient A's oxygen saturation level was 75% (normal oxygen saturation level is between 95% and 100%). LVN 1 stopped the G-tube feeding infusion, rendered care to the resident, and called the RT. The RT reported suctioning a large amount of feeding from the tracheostomy site. The note further showed the G-tube feeding was running over 30 minutes (based on the resident's order for tube feeding, approximately 135 ml [a little more than half of a cup] of G-tube feeding would have infused directly into the resident's lung over the span of 30 minutes). Review of the Nursing Narrative Note entry by LVN 1 dated 1/7/23 at 0052 hours, showed at around 2000 hours, LVN 1 started Patient A's G-tube feeding. At around 2010 hours, CNA 1 and another CNA weighed Patient A. At 2045 hours, CNA 1 informed LVN 1 that Patient A was leaking from his tracheostomy stoma. Upon entering the room, LVN 1 observed Patient A was "desatting" at 75% oxygen saturation level and pale, and the G-tube feeding was connected to the resident's closed suction system. The note showed LVN 1 immediately turned off the tube feeding and suctioned the resident. The note further showed when CNA 1 was asked about the incident, CNA 1 responded the G-tube feeding got disconnected and she reconnected it back, but unfortunately, CNA 1 connected it to the wrong port. Patient A was transferred to the acute care hospital at 2020 hours. Review of Patient A's SBAR (undated) showed the following: - Situation: Patient A had G-tube feeding connected to the saline injection port of his closed suction system. - Background: CNA 1 saw the saline infusion port of the resident's closed suction system and connected the G-tube feeding to it. About 20 minutes later, CNA 1 noticed there was white fluid leaking from Patient A's tracheostomy stoma and notified LVN 1. - Assessment: CNA 1 should not have manipulated the G-tube feeding. - Recommendation: All CNA staff educated on their scope of practice and instructed not to manipulate support equipment and alarms. On 1/19/23 at 0935 hours, an interview, concurrent closed medical record, and facility document review was conducted with the Nurse Manager. The Nurse Manager verified the above findings. The Nurse Manager stated it was discovered that the G-tube feeding was mistakenly connected to and infusing through the saline port of the resident's closed suction system on 1/6/23. The Nurse Manager stated CNA 1 said she was trying to be helpful by connecting the G-tube feeding but later realized she had connected it to the wrong port when she observed fluid coming from the resident's tracheostomy site. An observation of the G-tube and saline port of the closed suction system showed both ports looked similar, with the Nurse Manager adding that she was an experienced nurse and both ports looked very similar and could easily be mistaken for the other. The Nurse Manager verified it was not with the CNA's scope of practice to administer or manipulate the G-tube feeding or closed suction system. On 2/9/23 at 1410 hours, a telephone interview was conducted with LVN 1. LVN 1 verified the findings of his Nursing Narrative Note entry. LVN 1 stated at around 2000 hours on 1/6/23, he started Patient A's tube feeding after checking for the correct placement. LVN 1 stated CNA 1 and another CNA had weighed the resident shortly after this. LVN 1 stated at around 2045 hours, CNA 1 informed him there was fluid leaking from around Patient A's tracheostomy stoma. LVN 1 reported seeing the G-tube feeding connected to and infusing through the saline port of the closed suction system when he entered the room. LVN 1 stated there was feeding coming out from the resident's tracheostomy site and tubing. LVN 1 stated he asked CNA 1 what had happened, and CNA 1 stated the G-tube feeding got disconnected and she connected it to the port. LVN 1 stated he asked CNA 1 why she did not call for help instead, but CNA 1 did not respond. LVN 1 verified it was not within the CNA's scope of practice to connect or disconnect the G-tube feeding. Review of CNA 1's written statement (undated) showed CNA 1 discovered Patient A's G-tube feeding was disconnected. CNA 1 noted the resident had something covering his neck with something protruding that looked "like that is where to connect the food. " CNA 1 proceeded to connect the G-tube feeding to the port because she did not want the resident's shirt to get wet. LVN 1 was notified after CNA 1 noticed the resident was leaking from the tracheostomy site. LVN 1 discovered the resident's G-tube feeding was "connected to the wrong end. " Review of the acute care hospital's ED Note-Physician dated 1/6/23 at 2249 hours, showed Patient A's G-tube feeding was connected to his tracheostomy tube for approximately 30 minutes today around 2045 hours; unsure how many ml of the tube feeding was infused. Following the incident, Patient A presented with respiratory issues. Under the section for Differential Diagnosis, the physician documented iatrogenic (medical disorder, illness, or injury caused in the process of medical treatment) aspiration pneumonia, pulmonary hemorrhage. Upon suctioning, there was blood tinged/brown fluid from the tracheostomy, likely related to tube feeding mixed with blood. The chest x-ray showed significant bilateral infiltrates with concern for aspiration pneumonia. Patient A was admitted to the PICU and treated with antibiotics. Review of the acute care hospital's PICU Progress Note dated 1/20/23 (Day 13 of Patient A's hospital stay), showed Patient A's diagnoses included acute on chronic respiratory failure with hypoxemia and aspiration pneumonia (pneumonitis due to inhalation of food and vomit). Under the section for Assessment/Plan, the physician documented Patient A was admitted after being accidentally fed through his tracheostomy, was more lethargic than usual for the last few days, and the resident's ventilator settings were increased due to hypercapnia (a buildup of carbon dioxide in the bloodstream). This violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result.