**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** All times are in Eastern Daylight Time (EDT) unless otherwise noted. Based on interview and record review, the facility failed to replace a feeding tube in accordance with professional standards of practice for one Resident (#1) of two residents reviewed for enteral nutrition, which resulted in Immediate Jeopardy when Resident #1 subsequently suffered aspiration pneumonia requiring admission to the Intensive Care Unit (ICU) and ultimately resulted in Resident #1 being placed on comfort care measures. The Immediate Jeopardy (IJ) began on 1/11/25 when Registered Nurse (RN) J inserted a urinary catheter with 30 cc (cubic centimeter) balloon into the gastrostomy site of Resident #1 (R1) to use as a feeding tube. After the urinary catheter was placed, R1 experienced blood-tinged vomiting, an oxygen saturation (SPO2) level of 82%, and a decreased heart rate of 42 beats per minute. R1 was noted to be cool and clammy with a hardened abdomen. R1 was transferred to the hospital on 1/11/25 where x-ray examination confirmed the urinary catheter balloon was inflated in R1's esophagus. The Administrator (NHA) was notified of the Immediate Jeopardy on 2/27/25 at 4:00 PM. This surveyor confirmed by interview and record review that the immediacy was removed on 2/28/25 at 2:17 PM, however, noncompliance remained at the potential for more than minimal harm due to sustained compliance which has not been verified by the State Agency (SA). Findings include: According to the EMR, R1 was transferred to the Emergency Department (ED) on 1/11/25 and was admitted to the ICU with aspiration pneumonia (an infection that occurs after a large amount of food or liquid is breathed into the lungs) after RN J inserted a urinary catheter in his gastrostomy site. A radiology examination in the hospital on 1/12/25 at 12:38 AM CT revealed the balloon portion of the urinary catheter was inflated within R1's esophagus. R1 was placed on comfort measures and returned to the facility on 1/13/25. A telehealth provider document dated 1/11/25 at 6:19 PM CT documented the provider was notified by RN J regarding R1 vomiting and coughing up copious amounts of white foam. RN J conveyed to the provider that R1 had a G-tube, and congestion was heard throughout R1's lung fields. RN J requested provider instruction regarding when to re-start R1's tube feeding. According to the documentation by the provider on 1/11/25 at 6:19 PM CT, the provider called RN J and was told by RN J that R1 had a Foley (urinary catheter held in place by a balloon) chronically. The provider documentation did not indicate RN J had informed the provider that a new Foley catheter had been inserted prior to R1 experiencing the symptoms of concern. The provider ordered Zofran (a medication to treat vomiting) and Duoneb (a combination medication to relax the airway and improve breathing). The provider ordered the tube feeding to be withheld for four hours and to obtain R1's vital signs every four hours for 24 hours. Telehealth provider documentation dated 1/11/25 at 9:30 PM CT documented RN J again contacted the provider to report R1 had blood-tinged emesis and was cool and clammy with a hardened abdomen. The provider documented in part: .This provider returned call to facility and talked to [RN J], and [RN J] states patient had pulled his G-tube out so replaced it and now noted that white milky pink type of fluid now patient is cool and clammy abdomen is hard. This provider inquired if an abdominal x-ray was done after replacing the feeding tube and [RN J] states they cannot do x-rays at the facility and will need to send patient out to ED [Emergency Department]. This provider discussed with [RN J] patient really needs to have x-ray done to make sure that the tube feedings in correct place and also since his oxygen saturation is 82% on room air please [sic] patient on oxygen and send patient to ED . The provider ordered R1 transferred to the ED via ambulance for vomiting and gastrostomy complication. The provider further documented, Patient presents with ongoing emesis and earlier had removed his G-tube and it was replaced by the nurse and now his abdomen hard: emesis secondary to G-tube malfunction. A Hospitalist note dated 1/12/25 documented, in part: .G tube replaced yesterday, and later he appeared to aspirate after vomiting. He was hypoxic on EMS arrival and in ER, required 6 L [oxygen] per NC [nasal cannula - a tube used to deliver oxygen]. He was later switch to oxymask [mask used to provide a broad range of oxygen concentrations] as he was breathing through his mouth . Reviewed pt hx [history] with SNF [Skilled Nursing Facility] nurse. Prior tube was noted to be leaking, so new tube was placed. He received approximately 50 ml of feeding and was noted to vomit and possibly aspirate . G tube was noted to be displaced, reviewed imaging with radiologist who reevaluated placement on CT [scan] and distal end of tube was in esophagus with balloon inflated in distal esophagus with tip facing superiorly [aimed towards the head]. Confirmed with x ray with gastrografin [contrast agent used for x-rays] via tube per radiology recommendation. Tube was initially withdrawn and reimaged. General surgery was consulted and replaced foley tube that was present with MIC-KEY tube [a low-profile gastrostomy feeding tube] . A hospital Discharge summary dated [DATE] reiterated a foley catheter was placed in R1's gastrostomy site at the facility and R1 began vomiting and became short of breath with presumed aspiration after vomiting. The summary documented, in part: .Given the patients age and comorbidities, as well as acute illness with hypoxia and respiratory distress .discussion was held with the patent's brother who is [R1's] active POA (Power of Attorney) regarding plan and goals of care. [R1's brother's name redacted] opted to keep [R1]comfortable . [R1] has intermittently taken Ativan and morphine via IV to help with comfort and dyspnea which have been effective . A nurse's note entry on 1/12/25 at 2:44 PM CT documented a discussion between a facility nurse and a nurse from the hospital. The nurse's note documented R1 was expected to return to the facility on 1/13/25 and was being placed on comfort measures. R1 returned to the facility on comfort measures on 1/13/25 with a MIC-KEY in place. An untimed re-admission progress note dated 1/13/25 documented, in part: .Patient was re-admitted to [name of facility redacted] 2nd floor Nurses station on 1/13/25 from [name of hospital redacted] at 4:05 PM [CT] via [name of ambulance transport redacted] following a 3-day stay related to aspiration pneumonia and complications of gastrostomy Tube. Rehabilitation Potential is poor related to monitoring of G-tube and pneumonitis [inflammation of the lungs] status . A nurse's note by RN J dated 1/16/25 at 8:54 PM CT documented as late entry for 1/11/25, read in part: . fluid coming from around g-tube site. Tube feeding was stopped. Existing tube was removed without difficulty . New g-tube/catheter was inserted .balloon inflated .Tube feeding was again restarted. Re-entered room to observe resident vomiting a white/pink opaque liquid .Telehealth was contacted . Returned to room, placement was verified via auscultation, Zofran was administered .Within 5 minutes, nursing assistant was calling for nurse, upon entering room, resident was vomiting same white/pink opaque liquid. Suctioning immediately started. SpO2 [oxygen saturation] at 82% RA [room air]. O2 [oxygen] applied via nasal cannula at 2 L [liters] and telehealth was contacted again, orders obtained to transfer resident to local ED to eval (evaluate) and imaging for proper g-tube placement . R1's EMR did not contain documentation by RN J on 1/11/25 of the circumstances surrounding the feeding tube concerns that resulted in R1 being transferred to the hospital on 1/11/25. Review of consecutive nurses' notes on 1/11/25 revealed an entry dated 1/11/25 at 5:09 PM CT documenting R1's feeding tube was flushed with 540 ml (milliliters) of water, 117.5 ml of liquid medications were provided through the feeding tube, and tube feeding was being administered at 55 ml per hour. The next nurse's note on 1/11/25 at 6:29 PM CT documented a PRN (as needed) medication was administered through the feeding tube. The following progress note at 8:10 PM CT documented Duoneb had been withheld. Subsequent nurses' note entries on 1/11/25 included R1's vital signs and notation R1 was transferred to the ED on 1/11/25 at 10:05 PM for hypoxia (low oxygen level), persistent emesis, low heart rate, and congestion throughout the lung fields. A nurse's note entered on 1/11/25 at 10:28 PM documented R1 had a pulse of 42 (beats per minute), a respiratory rate of 24 (breaths per minute), and an oxygen saturation of 82% on room air, for which supplemental oxygen at two liters per minute was administered. On 2/25/25 at 3:18 PM, R1 was observed lying in bed with labored, rapid respirations. R1 had audible rhonchi (gurgling sounds) with inhalation and expiration. A tube feeding pump was next to R1's bed without tube feeding connected. Review of R1's Electronic Medical Record (EMR) revealed admission to the facility 1/22/99 with a primary diagnosis of cerebral palsy. The EMR documented R1 was unable to consume foods or fluids orally and required enteral feeding for nutrition and hydration through a gastrostomy tube (G-tube, a tube placed through the abdominal wall into the stomach for delivery of food, fluid, and medications). A quarterly Minimum Data Set (MDS) assessment dated [DATE] documented R1 was nonverbal and had short-term and long-term memory impairment. A Brief Interview for Mental Status (BIMS) could not be completed due to R1 never being understood. The MDS coded R1 as being dependent on staff for all activities of daily living. RN J was interviewed on 2/26/25 at 10:14 PM. RN J said R1 pulled his feeding tube out on 1/11/25 at approximately 4:30 PM CT so RN J replaced the tube with a 16 French foley catheter (catheter with diameter of 5.3 millimeters) with a 30-cc balloon. RN J said placement of the tube was verified through auscultation (listening with a stethoscope) using air injected from a piston syringe into the tube. When asked if residual was checked, RN J said it was but could not recall the amount of residual. RN J said after the tube was inserted, medications were administered and R1's tube feeding was started. RN J said about an hour after starting tube feeding, R1 was observed with a foam-like substance coming from the mouth. RN J alleged R1 was suctioned, the tube feeding was stopped, and the telehealth provider was notified. RN J said instruction was received by the provider to administer Zofran and Duoneb to R1, and to check placement of the tube after four hours and if all was good to restart the tube feeding. RN J said the Zofran was administered through the tube. RN J said about an hour after administering the medications, R1 commenced vomiting. The telehealth provider was contacted again, and orders were received to transfer R1 to the hospital ED. RN J said that on 1/13/25 or 1/14/25 the Director of Nursing (DON) asked about the situation and events with R1 on 1/11/25. RN J said the DON directed her to enter documentation about the event in R1's EMR. RN J acknowledged not documenting the situation on 1/11/25 with R1 until 1/16/25, five days after the events that lead to R1 being transferred and admitted to the hospital. RN J said there was no provision or offer of teaching or training in response to the event with R1 on 1/11/25. RN J was asked if training or competency evaluations on changing a feeding tube or inserting a urinary catheter in lieu of a gastrostomy tube had ever been conducted. RN J responded, No - we don't really have training, just online videos we watch unless there's something out of the ordinary like wound vacs. RN J acknowledged never receiving training or competency evaluations for changing a gastrostomy tube or inserting a urinary catheter as a feeding tube. The education and training records and the competency evaluations for RN J were reviewed on 2/26/25 and revealed no education or competencies for changing a gastrostomy tube or inserting a catheter to be used as a gastrostomy tube. Licensed Practical Nurse (LPN) K was interviewed on 2/27/25 at 8:15 AM. LPN K indicated they had 24 years of employment at the facility. LPN K said R1 had been in the facility since the 1990's and had used a catheter as a feeding tube for many years. LPN K said nurses had been changing R1's catheter for years. LPN K said another floor nurse showed LPN K how to change the catheter but confirmed never receiving training, or competency checks for inserting the catheter as a feeding tube. LPN K said R1 had a history of pulling the catheter causing it to become dislodged. LPN K stated a securement device had never been used to stabilize the catheter to keep R1 from causing the tube to become dislodged. LPN K said the facility did not have securement devices. LPN K said R1 had a MIC-KEY tube now and if the MIC-KEY comes out they will need to send R1 to the hospital because the nurses cannot change MIC-KEY tubes in the facility. Unit Manager/RN L was interviewed on 2/27/25 at 8:21 AM. RN L said the facility completed competency evaluations on nurses but the competencies did not include changing of gastrostomy tubes or inserting a catheter as a feeding tube. RN L denied receiving training or competency evaluations on changing of gastrostomy tubes or inserting a catheter as a feeding tube. RN L said securement devices were not used in the facility with G-tubes or with catheters used as feeding tubes. When asked about changing a MIC-KEY tube, RN L said, We don't change MIC-KEY tubes - that's done in the hospital. The education and training records and the competency evaluations for LPN K and RN L were reviewed on 2/27/25 and revealed no education or competencies for changing a feeding tube or inserting a catheter to be used as a gastrostomy tube. The Director of Nursing (DON) was interviewed on 2/27/25 at 11:42 AM. The DON said she was notified by a hospitalist about the catheter being identified in R1's esophagus with the balloon inflated. The DON said she reviewed the facility policies and determined the policy was followed because tube placement was verified according to the documentation. When asked to which documentation she was referring, the DON replied the nurse signed out verification of tube placement on the TAR (Treatment Administration Record). The DON said an investigation was not completed but acknowledged speaking to RN J after being called by a hospitalist the day R1 returned to the facility (on 1/13/25). The DON acknowledged instructing RN J to enter the documentation into R1's EMR. When asked if she had any concerns with the catheter found lodged in R1's esophagus with a 30 ml balloon inflated and subsequent blood-tinged emesis and hypoxia, the DON responded, I think the tube got in his esophagus when he aspirated. The DON confirmed R1 had not been assessed by a gastroenterologist to determine if a urinary catheter in lieu of a feeding tube was beneficial to R1. The DON confirmed R1's physician had no recent documentation for the reason a urinary catheter was used as a gastrostomy tube. The DON said if the physician had documented the risk versus benefit of using a urinary catheter in place of a gastrostomy tube it was years ago. No physician documentation was provided by the end of survey. When asked if any training or competency evaluation had been completed with RN J or the other nurses in the facility, the DON acknowledged no training or competency evaluations had been completed. The DON said nurse competencies should be completed yearly but the competencies did not include changing a feeding tube or inserting a catheter as a feeding tube. When asked why securement devices were not used with feeding tubes, including urinary catheters used as feeding tubes, to help secure the tubes in place and prevent dislodgment or migration of the tubes, the DON replied she did not know why securement devices weren't used. When asked if MIC-KEY tubes were replaced in the facility, the DON replied, We can. We have a policy. The DON did not provide a response when asked if nurses had been trained and competency evaluated on changing MIC-KEY tubes. R1's January 2025 TAR was reviewed and did not reveal documentation by RN J that catheter placement was verified on 1/11/25. The Facility Assessment (FA) dated 1/2025 documented tube feeding as one of the services and cares offered at the facility. The section of the FA for nurse education did not include changing feeding tubes or inserting urinary catheters for use as feeding tubes. R1's physician's orders with start dates after readmission on [DATE] were reviewed on 2/27/25. The orders were signed by R1's physician on 1/16/25 at 8:52 AM CT and contained an active order: Change G tube foley catheter 16 Fr with 30 cc balloon **MUST USE LATEX CATHETER** 1 X [time] month 2nd Sat [Saturday]. The physician's orders did not include an order for comfort care. The physician's orders did not include an order for a MIC-KEY tube. R1's care plan provided by the facility contained handwriting at the top of the first page that read; Readmit 1/13/25 reviewed no changes. The care plan did not include the use of the MIC-KEY or interventions to ensure placement of the tube or to direct staff what to do in the event the MIC-KEY was dislodged. A radiology technician from the facility's contracted provider of radiology services was interviewed on 2/28/25 at 9:06 AM. The technician confirmed the company he worked for provided mobile x-ray services for the facility. The technician said their services cover abdominal x-rays for verification of feeding tube placement. The technician said the facility was visited twice monthly or as needed at any time to provide x-ray services when needed and ordered by the physician. The DON was asked on 2/28/25 at 10:31 AM if the Medical Director was aware the nurses in the facility had not been trained and competency-evaluated on changing feeding tubes or the insertion of catheters in lieu of feeding tubes. The DON said the Medical Director was not aware. When asked about the expectations with care plans documenting interventions for the care and maintenance of feeding tubes, the DON said, There should be something in there. According to ASPEN (American Society for Parenteral and Enteral Nutrition) Safe Practices for Enteral Nutrition Therapy, Journal of Parenteral and Enteral Nutrition located at https://aspenjournals.onlinelibrary.[NAME].com/doi/10.1177/0148607116673053 and The National Library of Medicine, Chapter 17, 17.1. Enteral Tube Management found at www.ncbi.nlm.nih.gov/books/NBK593216/ Assessing Tube Placement: .Feedings or medications administered into an incorrectly placed enteral tube result in life-threatening aspiration pneumonia. The placement of an enteral tube is immediately verified after insertion by an X-ray to ensure it has not been inadvertently placed . After X-ray verification, the tube should be marked with adhesive tape and/or a permanent marker to indicate the point on the tube where the feeding tube enters the nares or penetrates the abdominal wall. This number on the tube at the entry point should be documented in the medical record and communicated during handoff reports. At the start of every shift, nurses evaluate if the incremental marking or external tube length has changed. If a change is observed, bedside tests such as visualization or pH testing of tube aspirate can help determine if the tube has become dislocated. If in doubt, a radiograph should be obtained to determine tube location Older methods of checking tube placement included observing aspirated GI contents or the administration of air with a syringe while auscultating (commonly referred to as the whoosh test). However, research has determined these methods are unreliable and should no longer be used to verify placement . The facility policy Tube Feeding dated as effective 3/2024 read, in part: Purpose: To ensure that staff providing care and services to the resident via a feeding tube are aware of, competent in and utilize facility protocols regarding feeding nutrition and care. Feeding tube care and services will be provided in accordance with resident needs and professional standards of practice . Prior to flushing the feeding tube, the administration of medication or providing tube feedings the nurse verifies the proper placement of the feeding tube by . a. Draw up 30 ml of air into a 60 ml syringe . c. Attach the syringe to the tube and inject the 30 ml of air into the feeding tube auscultating for placement . The policy did not include x-ray verification for placement after placing an enteral tube, the marking and documentation of the tube entry point, measuring of tube length, or bedside tests of aspirate if tubes are dislodged. The policy Care of Resident with Gastrostomy Tube dated as effective 3/2024 read, in part: .6. Secure tube with tape to prevent displacement of tube . The Immediate Jeopardy that began on 1/11/25 was removed on 2/28/25 when the facility took the following actions to remove the immediacy: 1. Affected Resident(s) / Other residents at risk: Resident R1 no longer has a foley catheter as a G-tube. The resident returned from the hospital with MIC-KEY low-profile tube in place. On February 27, 2025, the physician clarified that the orders to change the G-tube if plugged or compromised in any way is to be done at the hospital. The nurses are not to change the tube. 2. For current and new residents, On February 27, 2025 all residents receiving tube feeding were assessed for the presence of a G-tube. Only one was identified. [Resident reference redacted] On February 27, 2025 the physician clarified that the orders to change the G-tube if plugged or compromised in any way is to be done at the hospital. The nurses are not to change the tube. On February 28, 2025 the physician ordered Xray verification of the placement of current feeding tube to set a baseline for measuring. The facility's policies Gastric Tube Feeding and Policy and Procedure: Tube Feeding has been amended that the resident will be sent to the ED for replacement and measurements will be done to verify placement prior to medication administration, water flush, or start of formula. Also to notify the physician for any abnormalities including dislodging. The facility policy Insertion on indwelling catheter for gastric feeding has been removed. 3. All nursing staff working day shift have been educated on the policy changes and competency tested for measuring as of February 28, 2025.