The following reflects the findings of the Department of Public Health during a Complaint Investigation visit.
CLASS AA CITATION -- PATIENT CARE
F322 A resident who is fed by a naso-gastric 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 February 11, 2008, at 2:20 p.m., an unannounced visit was made to the facility to investigate a complaint that a nasal gastric tube (NGT) (a tube inserted into the nasal passage, down the throat and into the stomach through, which the resident is fed liquid nutrients) was incorrectly inserted and resulted in empyema (accumulation of pus in the space between the lung and the chest cavity (pleural space) and possible life-threatening injuries.
Based on record review and interviews the facility failed to ensure Resident I received the appropriate treatment and services to prevent the incorrect placement of the NGT. The facility failed to:
Notify the physician to receive a valid order to reinsert the NGT. Failed to properly insert the NGT and verify placement.
On February 11, 2008, a review of Resident is Admission Information Sheet, indicated she was readmitted to the facility on October 9, 2007, the resident's diagnoses included: acute respiratory failure, attention to tracheotomy (opening into the trachea), respiratory dependent status, cardiac arrest, food/vomit pneumonitis (inflammation of the lungs), post trauma pulmonary insufficiency and rhabdomyolysis (disintegration of muscle). A review of Resident 1's Minimum Data Set (standardized assessment form) dated December 18, 2007, indicated: the resident was comatose (no discernible consciousness), required total care from staff, had a feeding tube in place, and had full loss of all voluntary movements to the neck and both upper and lower extremities.
On February 11, 2008, a review of the Acute Hospital B Operative Report dated September 7, 2007, indicated an insertion of a gastrostomy feeding tube was attempted. However due to Resident 1's hiatal hernia (protrusion of the stomach upward into the chest cavity through the opening for the esophagus in the diaphragm) placement of the gastrostomy feeding tube was determined to be unsafe.
On March 12, 2008, a review of the resident's Physician's Orders for January 2008, included the following orders: September 11, 2007, check tube placement every shift and inspect tube site. On November 11, 2007, administer Fibersource HN (liquid nourishment) at 80 milliliters (ml)/hour for 20 hours by NGT pump to run from 2:00 p.m. to 10:00 am., and to be flushed with a minimum of 200 ml of water every 8 hours. On December 11, 2007, administer one unit dose of Atrovent (opens lung passages) 0.5 milligrams and one unit dose of Xopenex (prevents spasms of the lung passages) every four hours as needed for respiratory failure through a nebulizer (turns the liquid medication into a mist) attached to the ventilator tubing. A review of the resident's telephone Physician's Orders indicated on October 15, 2007, and December 24, 2007, the physician ordered a chest X-ray for the resident to assure correct placement of the NGT after reinsertion. A review of the X-ray results dated October 15, 2007, indicated there was a tracheostomy tube in position and there was a large hiatal hernia seen. Conclusion: Slight left lower lobe infiltrate. The findings are improved from October 2, 2007. A review of the X-ray results dated December 24, 2007, indicated there was a tracheostomy tube in position and the NGT was in a large herniated stomach. Conclusion: Moderate right lower lobe and modest left lower lobe infiltrates.
On March 26, 2008, a review of the resident's initial admission Physician's Enteral Orders (feeding tube) dated September 11, 2007, indicated by a check mark to replace the NGT on admission. The sections of the Physician's Enteral Orders that would indicate to replace the NGT as needed, when obstructed, or displaced were blank. Additionally, the orders on this form were received via the telephone to a nurse and the section of the form for the physician's signature and time were blank. There was no physician's signature approving and/or validating telephone orders received by the nurse. On March 24, 2009, at 4:00 p.m. the DON referred to this Physician's Enteral Orders as a standing order. Title 22 California Code of Regulations, Section 72317, states that standing orders shall not be utilized in skilled nursing facilities.
On March 12, 2008, during a review of the resident's care plans, two care plans for Resident 1's NGT care were found. One care plan was entitled; NGT feeding due to dysphagia (difficulty in swallowing) dated September 9, 2007. The approaches included check tube placement minimally once per shift and before instilling water, formula, and during medication administration. The second care plan entitled, Dependent on NGT for nutrition and hydration dated September 15, 2007, approaches included check tube placement every shift, monitor for tolerance and report problems to physician, monitor for signs and symptoms of aspiration (the drawing of a foreign substance into the respiratory tract) such as coughing, congestion and fever, and call the physician.
On March 12, 2008, a review of the facility policy entitled, Nasogastric Tube Insertion and Care, revised April 2001, received from the facility on March 3, 2008, included the following procedures: Verify that there is a physician's order for the insertion of a nasogastric tube. Review the resident's care plan and provide for any special needs of the resident. Verify placement of the NGT by forcefully injecting ten (10) cc of air into the tube, while listening to the abdomen with a stethoscope for a loud bubbling sound. Record the following on the resident's medical record: date and time the procedure was performed, verification of tube placement, the name and title of the individual (s) who performed the procedure, and how the resident tolerated the procedure.
On March 12, 2008, a review of the resident's License Nurses Progress Notes dated January 27, 2008, revealed the following: At 1:00 p.m., Staff B (licensed nurse) noted resident's NGT was "out'. The resident was not in any respiratory distress and her vital signs were: blood pressure (BP)-128/78, temperature (T)-97 (degrees Fahrenheit), respiration rate (RR) -18 (breaths per minute), and oxygen saturation (a measure of the percentage of oxygen in the blood) 96%. At 2:00 p.m., Staff B, H (licensed nurse), and K (respiratory therapist), went to the resident's room. Staff B re-inserted the NGT into the resident's right nostril. No resistance or coughing was noted. Staff B, H, and K checked the placement of the NGT by the following method: By injecting 10 ml of air into the NGT with no coughing noted. Residual (feeding formula remaining in the stomach) was checked with no residual noted. The open end of the NGT was placed in water and no bubbles were observed. There was no evidence the facility had a safe system of checking the placement of the NGT. According to the 6th edition of The Lippincott Manual of Nursing Practice, copyright 1996, the 4th edition of Nursing Procedures, copyright 2004, and the Nurse's Pocket Companion, copyright 1994, when confirming tube placement, never place the tube's end in a container of water. If the tube is in the trachea, the patient may inhale the water. At 2:30 p.m., Staff B continued to monitor the resident. The head of the bed was elevated, placement checked and the NGT was noted to be patent. No shortness of breath or respiratory distress noted. The resident's vital signs were: BP-124178, T-97.8, pulse (P)-80 (beats per minute), and oxygen saturation 96%. The resident's medications were given through the NGT and the NGT feeding was started. On January 28, 2008, at 6:05 a.m., the resident's ventilator alarm was beeping and indicated increased airway pressure (the alarm indicated the lungs were not functioning properly). At that time the Respiratory Therapist administered breathing treatment medications according to the physician's order dated December 11, 2007, the Respiratory Therapist was to administer Atrovent and Xopenex breathing treatment medications to open the airways in the resident's lungs to decrease the airway pressure. However the breathing treatment medications were not effective in opening the resident's lung passages and the airway pressure remained high. On January 28, 2008, at 6:10 a.m., 911 was called and assisted respiration by the Respiratory Therapist was started using the manual-breathing bag. On January 28, 2009, at 6:30 a.m., paramedics arrived and transferred Resident I to Acute Hospital A.
A Review of the Licensed Nurses Progress Notes indicated only one entry dated October 15, 2007, at 2:10 p.m., the Licensed Nurses Progress note indicated resident's NGT was out. This single entry indicated that Staff B reinserted the NGT, resident's physician was notified, and a chest X-ray was ordered to ensure the NGT was placed in the stomach of the resident. There were no other Licensed Nurses Progress notes presented by the facility indicating resident had her NGT reinserted.
On March 3, 2008, at 2:30 p.m., an interview was conducted with Staff B. Staff B stated on January 27, 2008, at approximately 12:30 p.m.-1:00 p.m., when he came back from lunch, he noticed resident's NGT had almost come out. Staff B stated at approximately 2:15 p.m., he asked Staff H to assist him in reinserting the resident's NGT. Staff B stated he reinserted the resident's NGT. Staff B stated he, Staff H, and Staff K, checked the placement of the NGT. Staff B stated he checked the NGT placement by inserting 10-15 milliliters of air with a syringe into the NGT and listening with a stethoscope over the abdominal area for a swooshing sound. Staff B stated he placed the open end of the NGT into a cup of water to check for any bubbles. Staff B stated if bubbles were formed in the water it would indicate the NGT was in the lungs. Staff B stated he did not see any bubbles form in the cup of water. There was no evidence the facility had a safe system of checking the placement of the NGT. According to the 6th edition of The Lippincott Manual of Nursing Practice, copyright 1996, the 4th edition of Nursing Procedures, copyright 2004, and the Nurse's Pocket Companion, copyright 1994, when confirming tube placement, never place the tube's end in a container of water. lithe tube is in the trachea, the patient may inhale the water. Staff B stated Staff H and K, also checked the resident's NGT placement using the same method.
Staff B stated he connected the resident's NGT to the feeding pump at approximately 2:30 p.m. and turned the feeding pump on to 80 ml/hour. Staff B stated he administered the resident's medications by NGT and flushed the NGT with 60 ml of water at 2:45 p.m. Staff B stated he reported to the next shift to observe the resident, since her NGT had been reinserted. Staff B stated the resident was in no distress when he left, no coughing noted, and no problems with her ventilator pressure. Staff B stated the NGT had come out before and he had replaced it more than a week ago. Staff B was not able to find any documentation that he or any other staff had replaced the resident's NGT recently. There was no evidence found in the medical record or presented by the facility, to indicate staff notified the attending physician of the NGT being out, if the staff asked the attending physician lithe NGT was to be reinserted, and if an X-ray was required after re-insertion of the NGT on January 27, 2008.
On March 6, 2008, at 7:10 a.m., an interview was conducted with Staff H. Staff H stated she assisted Staff B to reinsert the resident's NGT. Staff H stated she also checked resident's NGT placement. Staff H stated she inserted air through a syringe connected to the NGT and listened for a swooshing sound in the abdominal area of the resident. Staff H stated she heard the swooshing sound in all four quadrants of the resident's abdominal area, and placed the open end of the NGT into a cup of water and did not see any bubbles form. There was no evidence the facility had a safe system of checking the placement of the NGT. According to the 6th edition of The Lippincott Manual of Nursing Practice, copyright 1996, the 4th edition of Nursing Procedures, copyright 2004, and the Nurse's Pocket Companion, copyright 1994, when confirming tube placement, never place the tube's end in a container of water. If the tube is in the trachea, the patient may inhale the water.
On March 10, 2008, at 2:40 p.m., an interview was conducted with Staff K. Staff K stated Staff B reinserted the resident's NGT. Staff B and H checked the placement of the NGT by inserting air and putting the NGT open end in water. The facility failed to have a safe system of checking the placement of the NGT. According to the 6th edition of The Lippincott Manual of Nursing Practice, copyright 1996, the 4th edition of Nursing Procedures, copyright 2004, and the Nurse's Pocket Companion, copyright 1994, when confirming tube placement, never place the tube's end in a container of water. lithe tube is in the trachea, the patient may inhale the water. Staff K stated he listened to the residents lungs and did not hear anything abnormal at that time.
A discrepancy between Staff B's Licensed Nurses Progress Notes and interview was noted. Staff B stated he reinserted Resident 1's NGT at approximately 2:15 p.m. However, Staff B documented in the Licensed Nurses Progress Notes that the NGT was reinserted at 2:00 p.m. The Respiratory Therapist notes indicate that Resident 1 was in respiratory distress at 2:10 p.m. on January 27, 2008.
On March 12, 2008, a review of the Respiratory Therapy Services Ventilator Flow Sheet, dated January 27, 2008, indicated the following: At 11:15 am., Resident 1's respiratory rate was 18/minute, pulse was 74/minute, peak inspiratory pressure (PIP according to Egan's, Fundamentals of Respiratory Care, Ninth Edition, copyright 2008, is the highest pressure produced during the inspiratory phase, to overcome airway resistance and inflate the alveoli.) was 20, and oxygen saturation was 97%. At 2:10 p.m., the resident's respiratory rate increased to 25/minute, pulse increased to 90/minute, PIP increased to 30, and oxygen saturation decreased to 90%. At 7:30 p.m., the resident's respiratory rate was 38/minute, pulse 98/minute, PIP was 54, and oxygen saturation was 93%. On January 28, 2008, at 4:45 a.m., the resident's respiratory rate was 38/minute, pulse 108/minute, PIP was 44, and oxygen saturation was 91%. At 5:50 am., the resident's respiratory rate was 38, and oxygen saturation had decreased to 89%. The resident was transferred to the emergency room at 6:30 a.m. The increasing respiratory rate from 18 to 38 breaths per minute, the increasing PIP from 20 to 54, the increasing pulse from 74 to 108 beats per minute, and decreasing oxygen saturation from 97% to 89%, indicated increasing respiratory distress.
On February 11, 2008, a review of the resident's Acute Hospital A, Emergency Department Report Stat Admission record dated January 28, 2008, revealed the following: A chest X-ray performed in the Emergency Room, indicated the resident's had a pneumothorax (accumulation of air in the area between the lung and chest) of the right lung. Physician C (Emergency Room Physician) reviewed the chest X-ray and indicated the NGT was going into the right lung. Physician C inserted a chest tube (tube inserted into the chest cavity to drain fluid or air) into the right lung pleural cavity (space between the lung and the chest wall) and removed approximately 250-300 ml of feeding fluid. When the chest tube was connected to suction approximately another liter of fluid came out. Resident 1 was started on antibiotics. Physician C's diagnosis of the resident's included the following: Right-sided pneumothorax, right-sided pneumonitis (inflammation of the lung tissue), likely right-sided pneumonia (inflammatory illness of the lungs, the lung air sac filled with fluids), and a perforated lung from a misplaced feeding tube.
On February 11, 2008, a review of the resident's Acute Hospital A, Record of Death indicated the resident's expired at Acute Hospital A, on February 8, 2008, at 4:10 a.m., the resident's provisional diagnoses included shortness of breath, pneumonia and respiratory failure.
On August 20, 2008, the Department received the resident's Autopsy Report dated February 22, 2008, performed by the Los Angeles County Coroner's Department. A review of the Autopsy Report indicated Resident 1's death was due to pleural empyema (a collection of inflamed, infected fluid in a body cavity, typically the pleura) due to perforation of the NGT. A review of the Anatomical Summary indicated the following: 81 year-old nursing home resident admitted to the hospital in severe distress on January 28, 2008, with a pneumothorax and the NGT was found to be in the right pleural cavity. According to the Los Angeles County Department of Coroner's autopsy report, 1000 milliliters of fluid was drained from the pleural cavity. The drained fluids grew out heavy Streptococcus agalactiae (bacteria), moderate Group G beta-hemolytic Streptococcus, very light Proteus mirabilis (bacteria), and very light Serratia marcescens (bacteria). Diffuse swollen erythema (redness) (cellulitis) (inflammation of the cells) of the right chest wall a 7 x 7 x 8 centimeters phlegmon (inflammation of tissue) of the tube site and a right-sided pleural empyema (collection of pus in the pleural cavity). The resident expired on February 8, 2008.
On August 26, 2008, the Department received the Physician/Coroner's Amendment Death Certificate for the resident's, dated July 14, 2008. A review of the Amendment Death Certificate indicated the resident's immediate cause of death was changed from respiratory failure as a consequence of pneumonia and change to pleural empyema as a consequence of perforation of NG-tube.
On March 4, 2008, at 2:00 p.m., an interview was conducted with the Nursing Home Attending Physician (Physician A). Physician A stated the resident's cause of death was respiratory failure, pneumonia of the right lung secondary to feeding formula entering the right lung, and empyema of the right lung. The chest X-ray dated January 28, 2008, confirmed that the NGT went into the right bronchus. There was no indication of an opening between the esophagus and the trachea.
On March 11, 2008, at 3:15 p.m., an interview was conducted with Physician B (Acute Hospital A Radiologist). Physician B reviewed the resident's chest X-rays taken at the Acute Hospital on January 28, 2008, at 6:55 a.m. Physician B stated the January 28, 2008, X-ray indicated the NGT had passed along side the trach tube balloon (holds trach tube in position) down the trachea and into the lower outer portion of the right lung. The end of the NGT had passed through the right lung and was in the space between the lung and the chest wall.
The placement of the NGT into the space between the lung and chest wall (pleural space) was detrimental to the resident's health because this allowed the collection of the tube feeding formula, water, and medications in the pleural space of the right lung. The placement of the NGT in the pleural space would account for no air bubbles coming out of the end of the NGT when it was placed in water. The NGT tip was inserted through the lung and went into the pleural space where there is no exchange of air. When the NGT feeding pump was turned on, the feeding formula, water, and any medications given through the NGT collected inside the sterile area of the enclosed pleural space. This led to the development of a pneumothorax (caused by the accumulation of the fluids), which compressed the right lung, which caused respiratory difficulties for the resident. The fluids, which entered into the pleural space, also introduced bacteria into the pleural space and led to the development of empyema and pneumonia, which was determined to be the cause of death of the resident by the Coroner's autopsy.
On March 24, 2008, at 4:00 p.m., an interview with the skilled nursing facility's Director of Nurses (DON) was conducted. The DON stated the nurses checked the placement of the resident's NGT according to the facility's policy, Nasogastric Tube Insertion and Care, revised April 2001. Based on staff interview some of the nursing staff followed the Nasogastric Tube Insertion and Care policy to verify placement of the NGT, by injecting ten milliliters of air into the tube and listen with a stethoscope for a loud bubbling sound. However, the staff failed to follow the Nasogastric Tube Insertion and Care policy to verify if there was a physician's order for the insertion of the Nasogastric tube. There was no valid physician's order to reinsert the resident's NGT. The Nasogastric Tube Insertion and Care policy did not include placing the end of the NGT in water and checking for bubbles. The DON stated there must have been a fistula (abnormal passage) between the digestive tract and the respiratory tract where the NGT entered into the lung (However Acute Hospital A's emergency room chest X-ray dated January 28, 2008, revealed the NGT was inserted into the right bronchus of the lung.). The DON stated the resident's did not display any signs of distress until the morning of January 28, 2008, when her staff responded accordingly and transferred the resident to the acute hospital. The DON stated there was a standing order to reinsert the resident's NGT, on the Physician's Enteral Orders dated September 11, 2007, so they did not need to notify the physician. According to Title 22, California Code of Regulations, section 72317, Standing orders shall not be used in Skilled Nursing Facilities. The DON stated the resident's had the prior chest X-rays done due to the staff not being certain of the NGT placement. The DON stated the staff was certain of the NGT placement on January 27, 2008, so no X-ray was done.
The facility failed to ensure the resident received the appropriate treatment and services to prevent the incorrect placement of the NGT by failing to:
Notify the physician to receive a valid order to reinsert the NGT.
2. Failed to properly insert the NGT and verify placement.
The above violations either jointly, separately, or in any combination presented either an 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 Resident 1's death.