Health inspection·November 26, 2024

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observations, record review the facility failed to assess and monitor a Gastrostomy tube site for 1 of 2 residents (R2) reviewed for feeding tubes in a sample of 6. Findings include: R2's Face Sheet, not dated, documented that R2's original admission date was 9/30/3019 was readmitted to the facility on [DATE] with a diagnosis of dysphagia and adult failure to thrive. R2's minimum data set (MDS), dated [DATE], documented that R2 is moderately cognitively impaired. MDS indicated that she requires assistance with activities of daily living (ADL). R2 receives a mechanically altered diet. R2's Care Plan, updated on 10/07/2024, documented that R2 refuses to follow mechanical diet and chooses to eat regular textured food despite being educated on the risks of choking. Care plan dated 10/05/2024 documented that R2 receives tube feeding for support to nutritional oral intake. The goal is that R2 will be adequately nourished and hydrated as evidenced by maintaining weight. The approaches are flushes as ordered, keep head of bed elevated, monitor weight, notify physician of changes, observe for signs and symptoms of aspiration, observe for tube feeding tolerance, and tube feeding as ordered. R2's Physician Orders, dated 10/23/2024, documented to administer Nova Source Renal 2 237 milliliters (ml) via percutaneous gastrostomy tube (PEG); to flush gastrostomy tube (G tube) with 50 ml water before and after each tube feeding ordered at 9:00 am, 1:00 pm, 5:00 pm and 9:00 pm. R2's POS (Physician Order Sheet) documents an order dated 11/5/2024 to consult with dietician to adjust tube feeds based on oral intake. R2's Physician Progress Note, dated 10/8/2024, documented that R2 receives tube feeding via peg tube but has also passed her swallow and is able to take things by mouth but has poor intake. R2's Progress Notes, dated 11/12/2024, documented that G tube patent, placement verified per auscultation. Flushes as ordered without difficulty. R2's Progress Notes, dated 11/18/2024, at 1:51 pm, documented that R2 took morning medications and pain medications before leaving for dialysis by mouth crushed. R2 refused tube feeding stating it made her sick on the ride there. Page 1 of 3 145465 145465 11/26/2024 Jerseyville Nsg & Rehab Center 1001 South State Street Jerseyville, IL 62052

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few R2's Progress Notes, dated 11/18/2024 at 5:13 pm, documented Registered Nurse (RN) went to administer evening medications and resident stated she doesn't get anything that way anymore, pulled her shirt up and there was no g-tube present. Medical doctor (MD) made aware and R2 has been sent to hospital for possible reinsertion. R2 had stated that it had been out for a few days. R2's Progress Notes, dated 11/20/2024 at 2:58 pm, documented R2 returned to facility from hospital yesterday (11/19/2024) following admission for G-tube removal observation/monitoring. Area to abdomen where G tube was removed clean and dry. No drainage or signs and symptoms of infection. On 11/25/2024 at 8:25 am, observed R2 in her room lying in bed, flat sleeping with oxygen on. Tube feeding supplies are noted sitting on her windowsill. Empty enteral feeding bag hanging on intravenous pole (IV) dated on bag of 11/4. On 11/25/2024 at 9:20 am, R2 stated she has been eating meals the entire time she has had G tube in. R2 stated her G tube was accidentally pulled out a week or two ago. R2 stated that she was in the hospital for 3 days. R2 doesn't remember how the tube was pulled out. R2 stated that she honestly didn't know why she ever had the G tube. On 11/26/2024 at 9:20 am V3, Licensed Practical Nurse (LPN) stated that she did not take care of R2 on 11/15/2024. V3 stated that the day before R2 had been moved from the 400- hall to the 200 -hall. V3 did remember that the morning of 11/15/2024, R2 had come up to V3 and had told her that her (R2) G tube was out. V3 stated that she thought R2 was her patient. R2 had told her that she did not want the G tube and that she had tried to pull it out in the past. V3 was asked regarding care of a G tube, and she stated she would assess it, put a dressing on it. V3 stated that she would try to document this assessment at least once per day in her progress notes. On 11/25/2024 at 3:40 pm spoke with V13, Certified Nursing Assistant (CNA). V13 stated that on 11/15/2024 she was on the 400- hall. However, she did get the front door when transport returned with R2 from hemodialysis. Transport stated that R2's G tube was out. V13 told him that she would tell her nurse and she told V3. On 11/25/2024 at 3:30 pm spoke with V14, RN. V14 stated that on 11/16/2024 she had charted not given for the 9:00 am and 1:00 pm entries for medications because she had followed an agency nurse who had not given R2 medications. V14 stated that it was around 5:00 pm - 5:30 pm and she gave R2 her medications orally. V14 planned to flush the g-tube but R2 told her it wasn't there anymore. V14 asked R2 if it was discontinued and R2 stated that it had been because she doesn't need it anymore. R2 told V14 that she was eating and drinking. On 11/25/2024 at 9:30 am spoke with V5, LPN. V5 stated that Monday morning, 11/18/2024, she gave R2 her medications orally and R2 refused her tube feeding. V5 stated that she did not observe or assess the tube feeding site and sent her to dialysis. V5 stated it was discovered Monday after dialysis that the G tube was not in place, and R2 was sent to the hospital. On 11/25/2024 at 3:17 PM V12, Emergency Medical Technician (EMT), stated that they received a call for transport for resident gastrostomy (G) tube replacement. V12 stated that he asked the 2 nurses present when it was the last flushed. V12 stated that he was informed that the G-tube was flushed on that day at 6:30 AM. V12 stated upon assessing the patient noted that the feeding site was scabbed completely over. V12 stated that the scabbed appeared to be there longer than a few hours. It didn't look like it had just been pulled out this morning. V12 stated that he sees this as neglect because 145465 Page 2 of 3 145465 11/26/2024 Jerseyville Nsg & Rehab Center 1001 South State Street Jerseyville, IL 62052

F 0693 Level of Harm - Minimal harm or potential for actual harm to say that a treatment was completed, and it is obvious that it wasn't is a problem. V12 stated that this is the first time I've seen a feeding tube that scabbed over when I was told it was flushed this morning. V12 stated that I would think it would have been longer and the ER (Emergency room) physician said that R2 would have to have surgery for placement of the G-tube. V12 stated that R2 stated that the tube came out on Friday prior. It threw up all kinds of red flags and I am obligated to report it. Residents Affected - Few The facility's Enteral Feeding Tubes: checking placement policy, dated July 2024, documents that It is the policy of Helia Healthcare that enteral feeding tube placement will be checked to confirm placement. Procedure: 1. The nurse will check enteral feeding tubes each shift and as needed. The facility's Tube Feeding: Bolus policy, dated July 2024, documents Procedure: 1. Check physician's order to determine type of feeding. 3. Verify placement of the tube 145465 Page 3 of 3