Next up on the CMSCG Blog “Ftag of the Week” series, we will be looking at F693 Tube Feeding Management/ Restore Eating Skills. F693 addresses assisted nutrition and hydration and enteral nutrition – tube feeding.
F693 – Regulatory Requirements
The regulation under F693 includes assisted nutrition and hydration, specifically:
- Naso-gastric tubes
- Gastrostomy tubes
- Percutaneous endoscopic gastrostomy
- Percutaneous endoscopic jejunostomy
- Enteral fluids
Per Appendix PP, providers are responsible for ensuring that a resident who has been able to eat a sufficient amount alone or with assistance is not fed by enteral methods unless, based on the resident’s comprehensive assessment, it bas been determined that the resident’s clinical condition indicates that enteral feeding is clinically indicated and consented to by the resident. The facility is also required to ensure that a resident who is being fed enterally receives appropriate treatment and services to:
- Restore oral eating skills, if possible, and
- Prevent complications of enteral feeding
Potential complications related to enteral feeding include aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and/or nasal-pharyngeal ulcers, so there’s a lot that needs to be considered when the decision is made to provide this type of feeding as the potential for complications should not be taken lightly.
As always, we’ll begin with a review of definitions for this regulation included in Appendix PP of the State Operations Manual (SOM).
Definitions
“Bolus feeding” – administration of a limited volume of enteral formula over brief periods of time.
“Continuous feeding” – uninterrupted administration of enteral formula over extended periods of time.
“Enteral feeding” (“tube feeding”) – delivery of nutrients through a feeding tube directly into the stomach, duodenum, or jejunum.
“Feeding tube” – medical device used to provide liquid nourishment, fluids, and medications by bypassing oral intake.
There are two basic categories of feeding tubes -nasogastric and gastrostomy. The type of feeding tube used must be based on clinical assessment and the needs of the resident. The SOM includes definitions to various types, including:
“Gastrostomy tube” (“G-tube”) – tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications. The most common type is a percutaneous endoscopic gastrostomy (PEG) tube.
“Jejunostomy tube” (“percutaneous endoscopic jejunostomy” (PEJ) or “J-tube”) – feeding tube placed directly into the small intestine.
“Naso-gastric feeding tube” (“NG tube”) – tube that is passed through the nose and down through the nasopharynx and esophagus into the stomach.
“Trans gastric jejunal feeding tube” (“G-J tube”) – feeding tube that is placed through the stomach into the jejunum and that has dual ports to access both the stomach and the small intestine.
Considerations, Potential Risks and Benefits
The Interpretive Guidance (IG) for this regulatory requirement includes extensive information on considerations for when a tube feeding may be appropriate despite the potential for a significant impact to the resident’s quality of life. This is a good area to start with before getting into the clinical components, where CMSCG Clinical Consultant, Mary Quinn, will add some food for thought in the next parts of this CMSCG Blog Series.
As indicated above in the regulatory requirements, feeding tubes can’t be used without a valid clinical rationale. The use of a feeding tube also requires consent from the resident, or the resident representative, if applicable. Consent needs to include education, especially around the risks and benefits, because the IG indicates that use of a tube feeding has a “major impact” on the resident’s quality of life, so it’s important to ensure use of this method of nutritional support aligns with the preferences of the individual resident.
Potential Benefits
The IG includes a list of potential benefits from use of a tube feeding, which include:
- A means to address the resident’s malnutrition and dehydration
- Promotion of better wound healing
- Assisting the resident with gaining strength
- The potential benefit of restoring the resident’s eating ability
- The potential for restoring the resident’s oral feeding
Although these benefits are included in the guidance, the IG also indicates that use of a feeding tube may potentially have an adverse effort on a resident’s clinical condition.
Potential Risks
The list of potentials risks associated with the use of a feeding tube include:
- Potential tube-associated complications
- Diminished socialization/ potential for social isolation
- Lack of opportunity to experience eating – taste, texture, chewing
- Reduced freedom of movement
Psychosocial Considerations
It’s important to consider that even if there are benefits, residents have the right to maintain their highest quality of life, so care and services need to be balanced against the risk of a negative psychosocial impact. Residents using a feeding tube may experience diminished socialization because they are not joining others during communal dining times. They also do not receive assistance with meals like other residents who may not be eating in a dining room or who require assistance with eating, so their interaction with staff can be limited as well.
In Part 2 of our CMSCG Ftag of the Week series for F693, we’ll discuss more about consent and then delve into some clinical details for use of feeding tubes.