Nursing Home Resident Nearly Dies After Temporary Employee Resets Feeding Tube Incorrectly

A nursing home was cited by its state department of health for resident neglect after it improperly set and monitored his feeding tube last July. This neglect nearly resulted in his death. After the feeding tube was reset, the resident received liquid feeding solution at a rate more than six times faster than prescribed.

The morning after the tube was reset, the resident, who is cognitively impaired and unable to speak, began to experience breathing difficulties and was transferred to a hospital, where he was diagnosed with aspiration pneumonia. This is a type of pneumonia caused by the inhalation of foreign matter into the lungs. This often happens when stomach contents enter the lungs after a bout of vomiting, according to Mayo Clinic staff.

"The resident was not expected to live but is in stable condition and was discharged back to the facility," the investigative report said.

The nursing home administrator explained that a nurse hired from a temporary service made an error in adjusting the resident's feeding tube pump. The error was discovered by staff, and the resident was quickly transferred to the hospital for care.

The event prompted the nursing home to launch its own internal investigation, and the administrator said: "Our investigation identified the error and the individual responsible. We subsequently asked the temporary agency we were using not to allow that person to return to our facility."For more, read the story.

We have represented several clients who had their feeding tubes improperly adjusted, reinserted, or manipulated by nursing home staff. In one of those cases against an area nursing home, the patient died days after his PEG feeding tube became dislodged at the facility and was replaced by a nurse who didn't first confirm proper placement.  Instead of being placed back into the stomach, the PEG tube was inserted into the patient's peritoneal cavity. 

The facility's nurse was negligent because the tract for the feeding tube was of questionable maturity when the nurse attempted "blindly" to reinsert the feeding tube.  Endoscopic or radiographic (x-ray) guided replacement of the tube, which was not done, was required in the absence of a mature tract.  The nurse also failed to confirm proper placement of the tube either radiographically using a water-soluble contrast or by aspirating gastric contents with a syringe and testing the aspirate for pH to confirm proper intragastric position before starting to tube feed. 

When tube feeding resumed, feeding formula was pumped into the periotneal cavity and resulted in peritonitis (infection of the lining of the abdominal wall), sepsis (systemic bacterial infection of the body), and an eight-day hospitalization during which the patient died.  According to the patient's long-time primary care physician, his life expectancy at the time of the neglect was six months due to pre-existing and unrelated medical conditions.

The case was settled well before trial.  The settlement terms are confidential at the nursing home's request.
Robert W. Carter, Jr. is a Virginia attorney whose law practice is dedicated to protecting the rights of the victims of nursing home and assisted living neglect and abuse in Richmond, Roanoke, Norfolk, Lynchburg, Danville, Charlottesville, and across Virginia. 

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