The Statement of Deficiencies and Plan of Correction from the U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services that resulted from a survey of a Missouri nursing home that was conducted on August 14, 2017 stated that a resident died from overfeeding through the resident’s g-tube port because the feeding occurred over the period of one-half hour instead of the one-hour period ordered by the resident’s physician. The resident was known to be at high risk for aspirating due to underlying medical conditions.
The Missouri nursing home was also faulted for failing to promptly begin resuscitation efforts upon discovering the resident unresponsive in bed, failing to begin CPR, and for failing to call 911, as required by the nursing home’s policies and the resident’s care plan (there was no do-not-resuscitate order in the resident’s nursing home record).
The resident had suffered very serious injuries (including multiple fractures and a serious head injury) as a pedestrian involved in a motor vehicle accident that occurred on April 10, 2017. On April 17, 2017, the resident underwent an upper tracheostomy tube placement (a surgical hole through the front of the neck into the windpipe through which a breathing tube/trach tube was inserted to help the patient breathe) and percutaneous endoscopic gastrostomy (a procedure in which a flexible feeding tube was placed through the abdominal wall and into the stomach).
The patient was transferred to the Missouri nursing home by ambulance on July 14, 2017. At the time of admission, the resident was nonverbal, contracted, and bedridden but was also full code status and was documented by the nursing home staff as being responsible for self. The admission documents included an advance directive acknowledgement initialed by the resident’s family member that indicated that the resident elected not to execute any advance directive measures. The resident’s physician’s orders dated July 14, 2017 stated, in part: “-7/14/17, TwoCal high nitrogen (HN) (high calorie formula used for increased protein and calorie requirements) every four hours, infuse over one hour by pump-strict aspiration precaution; … ”
On July 23, 2017 at 4:00 a.m., a nurse at the Missouri nursing home administered the resident’s bolus tube feeding and watched 240 cc of TwoCal HN flow into the resident’s g-tube port. The tube feeding was completed at 4:30 a.m. After flushing the tube, the nurse disconnected it from the g-tube port and left the room.
Approximately one hour later, a nurse found the resident unresponsive in bed with tube feeding formula coming out of the resident’s mouth and nose. The nurse failed to assess the resident, immediately check the resident’s code status, perform cardiopulmonary resuscitation (CPR), and call 911 in accordance with the nursing home’s policy.
The Statement of Deficiencies stated, “Physician E said if the resident’s nurse saw the tube feeding formula flow into the resident’s g-tube port and then the formula flowed out of the resident’s nose and mouth, then the resident most likely aspirated or vomited the formula. A large amount of formula coming up through the resident’s nose and mouth at the same time would prevent the resident from being able to breathe. As soon as staff discovered that a full code resident was unresponsive to stimuli, they should immediately start CPR. A delay in initiating CPR could result in the resident expiring. Staff should call 911 for a full code resident whether or not they believed the resident was dead.”
The home was cited for placing residents in immediate jeopardy and could be fined for the incident.
If you or a loved one suffered harm while a resident of a nursing home in Missouri or in another U.S. state due to nursing home neglect, nursing home negligence, nursing home abuse, nursing home under-staffing, or resident on resident abuse, you should promptly find a local nursing home claim attorney in your U.S. state who may investigate your nursing home claim for you and file a nursing home claim on your behalf, if appropriate.
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