Health inspection·December 12, 2019

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 observation, interview, and record review the facility failed to administer enteral nutrition (liquid nutrition given through a tube into the stomach) and water flushes per physician orders. This affected two residents, (Resident #67 and Resident #88), of nine residents the facility identified as receiving enteral nutrition. Findings include: 1. Review of the medical record revealed Resident #88 was admitted to the facility on [DATE] with diagnoses that included dementia, seizures, hypertension, aphasia (inability to communicate) following cerebral infarction (stroke), hemiplegia (paralysis) affecting the right side, gastrostomy (tube placed into the stomach for liquid nutrition), and malignant neoplasm of temporal lobe (brain cancer). Review of Resident #88's care plan dated 10/09/19 revealed he required tube feeding due to dysphagia (difficulty swallowing). Interventions included the facility was to follow orders for enteral nutrition formula, duration, rate and flush orders. Review of the Comprehensive Nutrition Assessment, dated 10/21/19, revealed resident was NPO (nothing by mouth) and the enteral feeding order was Nutren 2.0 at 60 milliliters (ml) per hour for 20 hours per day, up at 10:00 A.M. and down at 6:00 A.M. Further review of the Comprehensive Nutrition Assessment revealed the nutritional goal for Resident #88 was to have adequate intake of enteral feeding and flushes for as long as tolerated. Review of the significant change Minimum Data Set (MDS) 3.0 assessment for Resident #88, dated 10/31/19, revealed Resident #88 received 51 percent or more of his total calories by tube feeding. Observation on 12/09/19 at 3:30 P.M. revealed Resident #88 lying in bed. The feeding pump was not running, and the tubing was draped over the top of the pole, not attached to Resident #88. Observation on 12/09/19 at 4:25 P.M. revealed the tube feeding pump for Resident #88 was not running and the tubing draped over the top of the pole, not attached to Resident #88. Interview on 12/09/19 at 4:28 P.M. with Licensed Practical Nurse (LPN) #310 confirmed the tube feeding for Resident #88 was not being delivered to Resident #88 as ordered. Review of Resident #88's physician orders revealed an order, revised 12/10/19. The order revealed Page 1 of 2 366350 366350 12/12/2019 Gardens of McGregor and Amasa Stone 14900 Private Dr East Cleveland, OH 44112

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Resident #88 was to receive Nutren 2.0 at 60 cubic centimeters (cc) per hour, up at 10:00 A.M. and down at 6:00 A.M. for a total volume of 1200 milliliters (ml) per day. Interview on 12/12/19 at 7:35 A.M. with Registered Dietician (RD) #311 revealed residents who received tube feeding typically had a two to four-hour period each day without the tube feeding. She stated this period made it easier for the aides to provide care to the resident. However, time periods free of tube feeding were only ordered if the resident was able to still receive the daily nutritional requirements. 2. Record review revealed Resident #67 was admitted on [DATE] with diagnoses which included unspecified dementia without behavioral disturbance, dysphagia (difficulty swallowing foods or liquids, arising from the throat or esophagus, ranging from mild difficulty to complete and painful blockage), and gastrostomy status (an opening into the stomach from the abdominal wall, made surgically for the introduction of food). Review of the Minimum Data System (MDS) 3.0 assessment dated [DATE] revealed Resident #67 was cognitively intact, required limited assistance for transfers and supervision with locomotion and eating. Review of physician orders for Resident #67 included orders for a consistent carb diet, regular texture and thin liquids dated 07/24/19 and every shift 120 milliliters of water flush via Percutaneous Endoscopic Gastrostomy (PEG) tube for patency dated 05/24/19. Observation on 12/09/19 at 2:16 P.M. revealed Licensed Practical Nurse (LPN) #307 flushing Resident #67's PEG tube. LPN #307 checked the placement of the PEG tube for accuracy of placement, placed the plunger in the opening of the tube then poured 100 milliliters of water in the PEG tube. LPN #307 verified she gave 100 milliliters of water at the time of observation. LPN #307 stated, Oops I was supposed to give 120. LPN #307 then gave an additional 20 milliliters of water. Observation on 12/11/19 at 9:08 A.M. revealed LPN #308 poured 100 milliliters of water into Resident #67's PEG tube and flushed the peg tube. LPN #308 verified she gave 100 milliliters of water at the time of observation. Follow up interview 12/11/19 at 9:22 A.M. with LPN #308 verified the order for 120 milliliters of water for the PEG tube flush. LPN #308 stated, Oh no, I should have given 120. 366350 Page 2 of 2