In Part one of our CMSCG “Ftag of the Week” for F693, we reviewed definitions included in the regulation and discussed some important considerations for use of a feeding tube. The Interpretive Guidance in Appendix PP provides a list of risks and benefits which we also reviewed in Part 1,including a reminder to providers to think about the potential psychosocial impacts on residents if this form of care may be provided.
As part of that discussion, we touched on the need for consent, which we’ll look into further now, before Mary Quinn, RN, MA, CMS Compliance Group, Inc. Clinical Consultant, provides some clinical insight related to the use of feeding tubes.
Consent
Not surprisingly, with the potential risks and potential for diminished quality of life, the decision to initiate a feeding tube must be thoroughly discussed with the resident and/or, as appropriate, the resident representative by an appropriate member of the clinical staff, most often the responsible medical practitioner. Per the IG at F693, “consent” is viewed as a discussion with the resident/representative, physician and/or other member of the IDT where the risks, benefits and process for receiving tube feedings has occurred and the resident/representative is in agreement. The resident has the right to make informed decisions regarding the treatment that he/she receives, including placement of a feeding tube. If a resident is admitted to the facility with a feeding tube already in place, the facility should review the rationale for initial placement, the resident’s current condition, and the resident’s goals of care at the nursing facility.
Before we move on, now is also a good time to remind readers that the decision to use a feeding tube not only needs to be based on a resident’s clinical condition and wishes/preferences, but also must be made with consideration for all applicable Federal and state laws and/or regulations regarding decision-making for life-sustaining treatments. The IDT is responsible for ensuring the continued appropriateness for use of a feeding tube, and any decisions to continue or discontinue use should be made with the resident (or representative, as appropriate).
Policies & Procedures
Due to the potential risks associated with using a feeding tube, this regulation includes a variety of requirements surrounding “technical aspects” of feeding tubes which require the facility to have an associated P&P. These include monitoring, care, and replacement, which we’ll review now.
Monitoring Placement of a Feeding Tube
Per the IG, facilities must have a P&P which addresses how staff will verify that the feeding tube is functioning properly before beginning a feeding and before administering meds. Here’s some things to think about:
- If there are concerns related to dislodgement or placement, x-ray confirmation is considered the most accurate method of verification.
- Auscultation is no longer recommended, but it is still an observed practice. Make sure staff have proof of education on file related to the current policy/ standard of care. Concerns have been noted when current competencies are not in place during observation of a resident with a gastric tube during survey related to medication administration, starting a new feeding, or how staff monitors the infusion rate and amount of a tube feeding actually administered.
- Monitoring of gastric residual volume (GRV) has become the standard of care, but monitoring of the external length of the tubing is also acceptable if the exit site was marked on insertion. Per the IG, this monitoring method is not applicable when a low-profile G-tube is in use since this tube sits at the skin.
There’s a lot of specifics in the IG related to monitoring GRV, which may be appropriate when a tube feeding is going to be initiated or for residents who are unable to report symptoms that indicate a feeding is not well tolerated, such as abdominal pain, nausea and/or bloating. Checking GRV would not be recommended for residents who are alert and able to report any of these symptoms to staff. The IG states that pH of GRV may indicate correct placement, but also remember that medication and feeding formulas can alter pH levels.
Each resident’s clinical condition should be considered when determining actions to be taken based on the amount of GRV. Actions to take based on the amount of GRV should be clear, consistent with facility policy and physician orders rather than a subjective determination of the nurse.
There’s a lot of specifics in the IG related to monitoring GRV, which may be appropriate when a tube feeding is going to be initiated or for residents who are unable to report symptoms that indicate a feeding is not well tolerated, such as abdominal pain, nausea and/or bloating. Checking GRV would not be recommended for residents who are alert and able to report any of these symptoms to staff. The IG states that pH of GRV may indicate correct placement, but also remember that medication and feeding formulas can alter pH levels.
- Each resident’s clinical condition should be considered when determining actions to be taken based on the amount of GRV. Actions to take based on the amount of GRV should be clear, consistent with facility policy and physician orders rather than a subjective determination of the nurse.
Care of the Feeding Tube
Facility P&P must also address care of the feeding tube, with the following in mind:
- Appropriate infection control precautions to minimize the risk of contamination – this is a good time to monitor your staff’s technique
- Routine monitoring and cleaning of the insertion site to identify, lessen or resolve potential skin irritation or local infection
- Provision of appropriate care to the resident – personal, skin, oral and nasal
- Flushes – frequency of and volume used for flushing, flushes related to medication administration, and what to do when a physician’s order does not specify the volume for flushes.
Issues with appropriate care of a G-tube have the potential for a high-level citation if there’s a negative outcome, likely Harm-level (G/H/I). Let’s see how this was cited in a complaint survey.
Complaint Survey – F693 S/S: H (Actual Harm – Pattern)
It’s not often that you see Scope & Severity H level citations, so this one caught our eye, but when you review the findings, the surveyor made a good case for why this was not an isolated event which could have warranted a S/S: G deficiency.
A facility failed to ensure two residents who had gastrostomy tubes (G-tubes) were provided with appropriate treatments and services in an effort to prevent potential complications associated with G-tubes.
Resident 1 experienced multiple complications associated with having a G-tube, including: dehydration, a clogged G-tube and weight loss, and was sent to the hospital and admitted. This resident had a G-tube placed while at a GI appointment, secondary to severe dysphagia, with orders for continuous feeding and water flushes every four hours. Staff found the resident’s tube feeding had disconnected and that the nurse who found the disconnected tube feeding attempted to flush the G-tube, but it was clogged. Per the dating on the feeding bottle, it had been empty for more than 48 hours. This was attributed to a change in dietary recommendations for the tube feeding, with one set of orders discontinued and new orders never activated. The resident was transferred to the hospital to have the tube unclogged. It was also identified that the night nurses were not replacing tube feeding bottles consistently and were not flushing the G-tubes. On interview, the resident’s roommate stated that the resident’s tube feeding alarm frequently sounded for more than two hours during the evening and night shifts before being addressed by staff.
Resident 2 also experienced multiple complications related to his/her G-tube, including: clogged G-tube, dehydration, vomiting and diarrhea. Per a Nurses’ Note, the resident was found vomiting on himself and the head of the bed was not elevated appropriately while the resident’s feeding was running. Resident 2 was also transferred to the ER after experiencing this change in condition and presenting with abnormal labs (high sodium and BUN). Precipitating this ER visit was a prior visit due to the resident being hospitalized secondary to vomiting. After that initial ER visit, the physician increased the number of G-tube flushes for hydration, but after the additional flushes were ordered, nursing staff did not resume the resident’s previous flush schedule.
Not surprisingly, when interviewed, all the nurses who took care of these residents on the night shift told the surveyor that they did not have education or training with G-tube feedings or hydration.
Feeding Tube Replacement
Here’s some things that should be addressed in your policy and procedures:
- Routine replacements may be scheduled or conducted on a PRN basis.
- When and who is permitted to reinsert a feeding tube should be clear, including if the tube can only be changed outside the facility.
- A physician order should be entered for tube replacement.
- Documentation of re-insertion should indicate the type/size of the feeding tube, who inserted it, how the procedure was tolerated, and which method was used to validate placement.
- There needs to be a mechanism in place to monitor tube replacement.
- If a tube is dislodged, an Incident/Accident report should be considered.
- Notification to the physician should be made in the event of a dislodgement.
In Part 3 of our “Ftag of the Week” series for F693, we’ll review key considerations and nutritional aspects of feeding tubes – along with some helpful thoughts from Mary Quinn.