The following reflects the findings of the Department of Public Health during a Complaint Investigation visit:
CLASS AA CITATION -- PATIENT CARE
Representing the Department of Public Health:
Surveyor ID # 22458, HFEN
The inspection was limited to the specific facility event investigated and does not represent the findings of a full inspection of the facility.
483.25 (g) Naso-Gastric Tubes. Based on the comprehensive assessment of a resident, the facility must ensure that--
483.25 (g) (2) A resident who is fed by anaso-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.
On 11/20/08, an unannounced visit was made to the facility to investigate a complaint regarding a gastrostomy tube (GT- a tube placed through the skin and the stomach wall to provide nutrition and medications) that had been incorrectly reinserted. Resident 1 expired on /08, due to complications.
Based on interview and record review, the facility failed to ensure that Resident 1, who was fed by aGT, received the appropriate treatment and services to prevent complications by failing to:
Ensure Resident 1's GT was properly reinserted into the resident's stomach through the stoma(surgically-created opening). The GT was inserted into Resident 1's peritoneal cavity located outside of the stomach, instead of into the stomach. (The peritoneum is a membrane that lines the inner abdominal wall and covers the organs within the abdomen). As a result, Resident 1 developed peritonitis (inflammation of the membrane which lines the inside of the abdomen and all of the internal organs), respiratory failure and septic shock. The resident expired six days after the GTwas wrongly reinserted.
On /08, a review of Resident 1's clinical record revealed the resident was a 78years old male, initially admitted to the facility on /08, and readmitted on /08. The resident’s diagnoses included Alzheimer's Disease (a type of dementia that affects memory, thinking, and behavior ), altered level of consciousness, history of stroke and dysphagia (difficulty swallowing).
According to the clinical record, the resident was transferred to the general acute care hospital(GACH) on /08, for placement of a PEG(percutaneous [procedure performed through the skin] endoscopic gastrostomy) tube due to his difficulty with swallowing. Resident 1 was then transferred back to the facility on /08, after theGT placement.
The Minimum Data Set (MDS – a standardized assessment and care planning ), dated /08,indicated the resident was severely impaired in his cognitive skills (never/rarely made decisions), was incontinent of both bowel and bladder functions,required extensive to total assistance with all of his activities of daily living, and received nutrition only through the GT.
Upon readmission on /08, the attending physician ordered the feeding formula ProBalance at 75cubic centimeters (cc) per hour to provide1500 cc, 1800 kilocalories (kcal) in 20 hours per day, by the way of a feeding pump. All medications were ordered to be administered through the GT.
A nurse’s note dated /08, at 2:30 p.m.,indicated the resident was in bed, agitated and had pulled out the GT. The attending physician(Physician 1) was informed and ordered the nurse to notify Physician 2. At 4:30 p.m., Physician 2ordered to insert a Foley (brand name of a flexible catheter commonly used to drain urine from the bladder) catheter to replace the PEG tube.
According to the nurse’s note, on the same day,/08, timed at 4:30 p.m., indicated Resident 1’s family member was concerned about the appropriate placement of the inserted catheter .Physician 3 was contacted and ordered an abdominal x-ray to verify placement of the Foley catheter. At 9:45 p.m., on /08, the x-ray result
confirming the catheter was in the stomach was relayed to Physician 3, who ordered to resume the tube feeding.
A nurse’s note dated /08, timed at 2 p.m.,indicated Physician 1 visited the resident and ordered to replace the Foley catheter with an actualGT, size 20 French when available.
On /08, at 9:45 a.m., LVN 1 documented in the nurse’s notes, the Foley catheter was replaced with a GT catheter size 20 French. The note indicated the GT was intact, patent and bowel sounds we represent.
On the same day, /08, at 2 p.m., LVN 2documented Resident 1 was noted with abdominal pain, the GT placement was checked and the air sound was delayed, but no abdominal x-ray was taken to verify GT placement. According to the nurse’s note, the GT was adjusted but the air sound remained delayed. Physician 4 (on call forPhysician 1) was informed and ordered to transfer the resident to the GACH for verification of the GT placement.
On /08, at 3 p.m., LVN 2 documented Resident1’s GT was in place, had moderate bleeding and the resident was complaining of severe abdominal pain related to the GT.
A review of the Emergency Department PatientCare Record dated /08, timed at 4:14 p.m.,indicated the resident was pale, diaphoretic(profuse, excessive sweating ), with increased moaning and bright red blood was noted coming from the GT. Upon arrival to the emergency room,the blood pressure was 94/64 millimeters of 10 (worst possible pain).are: blood pressure -rate 12 to 18 breaths per
mercury (mmHg), the heart rate was 120 per minute, the respiratory rate was 54 per minute, and the temperature was 102.2 degrees Fahrenheit.Resident 1’s pain was rated at 10 on a pain scale
from zero (no pain) toNormal vital signs120/80mm/Hg; respiratory minute; heart rate 60-80 beats per minute;temperature 97.8- 99.1 degrees Fahrenheit(National Institute of Medicine/National Institutes ofHealth website(www.nlm.nih.gov/medlineplus/ency/article/002341 .htm).
Resident 1’s oxygen saturation was 82% on 2 liters of oxygen. The normal oxygen saturation level is greater than 95 percent (%). Levels less than 95%indicate impaired cardiopulmonary function or abnormal gas exchange (Lippincott Williams &Wilkins 2009 Diagnostic Tests Made IncrediblyEasy! – 2nd ed. page 419).
The physician’s documentation in the EmergencyAdmission Note from the acute hospital dated/08, indicated the resident arrived in critical condition, there was diffuse (generalized) abdominal tenderness, blood was coming from the GT and from around the GT site, and there was decreased bowel sounds. Laboratory test results revealed white blood count (WBC - help in fighting infections.) of 20,000. Normal WBC range is 4,500-10,000 per microliter (National Institute of
Health website).A CT scan (computed tomography - radiological study) of the abdomen and pelvis performed on
/08, at 7:20 p.m. to evaluate the GT placement revealed the GT was within the anterior mesentery Continued From page 5
(double layer of peritoneum that suspends the lower part of stomach and upper portion of the small intestine from the back wall of the abdomen) of the central upper abdomen, outside the stomach lumen. The CT scan also revealed a moderate amount of intra peritoneal (within the peritoneal cavity) free air, as well as a small amount of hyper-dense (thick) fluid surrounding the GT tip.
The Emergency Department Patient Care Record documentation on /08, at 9:18 p.m. indicatedResident 1required intubation (a placement of a tube into the windpipe to maintain an open airway).While the resident was in the EmergencyDepartment on /08, a surgical consultation was conducted and revealed diagnoses of peritonitis(inflammation of the membrane which lines the inside of the abdomen and all of the internal organs)with pneumo-peritoneum (air or gas in the peritoneal cavity) and systemic sepsis(life-threatening infection of the bloodstream )probably secondary to peritonitis. The consulting surgeon recommended a laparotomy (surgical incision between the ribs and the pelvis into the abdominal cavity). The resident was sent to the operation room at 11:10 p.m.
The Operative Report dated /08, indicatedResident 1 underwent an exploratory laparotomy,small bowel resection (removal of part to the intestines) and placement of a new gastrostomy.The postoperative diagnoses were peritonitis and misplaced GT. The findings indicated the GT was outside the lumen (cavity) of the stomach and was removed. The wall of the stomach was intact and no perforated organs were noted.
A physician’s documentation in a Critical Care comfort care.care protocol9:35 p.m. The dysfunction,respiratory peritonitis,
Progress Note dated /08, revealed Resident 1was on mechanical ventilator (breathing machine)due to postoperative respiratory failure. The plan included aggressive fluid resuscitation and broad spectrum antibiotics.
Another physician’s documentation in a CriticalCare Progress Note dated /08, revealedResident 1's condition remained critical with poor prognosis. The plan included aggressive fluid resuscitation.
A Critical Care Progress Note dated 7/9/08,indicated Resident 1’s family member, who had advanced directive for decision making, along with other relatives, wanted to stop all life prolonging measures, all treatments and to limit the treatment to comfort measures and terminal care.
According to the Expiration Discharge Summary,dated /08, during the course of hospitalization,Resident 1 developed persistent renal dysfunction,worsening of the septic shock and multi-organ dysfunction. Given his multiple medical co-morbidities (presence of one or more diseases)and after discussion with the resident’s family member, the resident’s status became do not resuscitate (DNR) and was extubated (the tube
from the windpipe was removed) forThe resident was placed on comfort on /08, and expired on /08, at final diagnoses included GT pneumo-peritonitis, septic shock,failure, status post intubation, Escherichia coli bacteremia (bacteria in bloodstream) and right lower lobe pneumonia.
According to the Certificate of Death, the date of death was /08, at 9:35 p.m., with the cause of death indicating multi-organ failure, sepsis,peritonitis and chronic renal failure.
On /08, at 3:05 p.m., during an interview, LVN1 stated on /08, she replaced the Foley catheter which had been used as a feeding tube with a newGT, but did not indicate she had any problems during the reinsertion. LVN 1 also stated a GT was usually changed only if the tube became dislodged.She further indicated that approximately two hours after the insertion, the resident started to bleed from the stoma and complained of abdominal pain.
On /08, at 3:40 p.m., during an interview, LVN3confirmed that the placement of the tube was checked by him as well as by LVN 2 by auscultation of the stomach (listening for air which is injected through the GT). LVN 3 also stated there was minimal bleeding of the resident's stoma after the GT was replaced and the stoma appeared reddened and irritated. LVN 3further indicated he applied pressure to the stoma, which then stopped bleeding and the resident was transferred to the hospital after the physician was notified.
The facility's undated policy and procedure onGastrostomy: Tube Changes, indicated to check tube placement and patency using standard procedures. The standard procedures were not specified in the policy.
On /08, at 3:50 p.m., the administrator stated an x-ray is not done following reinsertion of a feeding tube unless it is ordered by the physician.
The facility failed to ensure that Resident 1, who was fed by a GT, received the appropriate treatment and services to prevent complications by failing to:
Ensure Resident 1's GT was properly reinserted into the resident's stomach through the stoma. TheGT was inserted into Resident 1's peritoneal cavity located outside of the stomach, instead of into the stomach. As a result, Resident 1 developed peritonitis, respiratory failure and septic shock. Resident 1 expired six days after the GT was wrongly reinserted.
The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result and was a direct proximate cause of the death of the resident.