I was reminded about the heightened vulnerability of feeding tube patients when I heard about how an investigation into the care of patients at a Connecticut Nursing Home revealed that staff were providing incompetent care to two patients at their facility. 

The state’s investigation confirmed that staff at the facility allowed one patient suffer extreme weight loss and another feeing tube patient to suffer noticeable dehydration during an admission to a New Haven, CT facility, now known as Paradigm Healthcare.

With respect the malnourished feeding tube patient, a review of the patient’s chart suggested that the patient lost an alarming 20 pounds during a 30-day period. 

Equally alarming was the similar mistreatment of patient with a gastric feeding tube who required a hospitalization due to dehydration.  A state report into the patient’s nursing home care determined that the nursing home staff failed to take any corrective measures when the feeding tube remained visibly clogged over an extended period --- with multiple shift changes.

While fines were dispensed for these incidents of troubling care, I find multiple episodes of similarly poor care--- at the same facility-- to be appalling. Given the fact that the harm to these nursing home patients occurred over an extended period--- where many different staff members were likely caring for these patients--- there clearly is a systemic problem when it comes to properly caring for feeding tube patients. 

As a nursing home lawyer, who has litigated feeding tube complication cases I find that many staff members fail to appreciate the potential complications related to tube feeding patients.  Similarly, I see troubling occurrences where staff  are in such a rush to work their way though the roster of feeding tube patients that they fail to take basic safeguards such as flushing out the feeding tube or keeping the patient elevated during feedings--- which can contribute to serious complications such as: 

• Aspiration
• Dehydration
• Infection
• Malnutrition
• Death

As a result of the medical families’ staff responsibility to properly care for patients with feeding tubes--- and ensure that the devices are safely maintained, any situation involving a feeding tube complication deserves to be analyzed from a liability standpoint to determine if legal action is necessary.

Related Nursing Homes Abuse Blog Entries:

Improperly Placed Feeding Tube Results In Systemic Infection Of Disabled Nursing Home Patient

Failure To Keep Bed Elevated To Blame For Nursing Home Patient's Death From Aspiration Pneumonia

Feeding Tube Mishap Results In Patient Death & Large Nursing Home Fine

Dysphagia In Nursing Home Patients May Contribute To Medical Complications Such As: Choking, Pneumonia Or Death

The recently filed nursing home negligence lawsuit names Rosewood Care Center of Alton and related parties for their role in an October, 2009 incident in which a nurse at the facility improperly inserted a feeding tube in the patient.  The incident was not timely recognized by staff at the facility which eventually enabled a systemic infection to take hold and required extended hospitalizations.  This case is pending in Madison County Circuit Court.  You can read more about this nursing home negligence lawsuit here.

Infections related to improperly placed feeding tubes

With a sizeable contingent of patients who require feeding tubes to provide their nutrients, nursing homes need to train staff on how properly tube feed patients, keep the tubes clean and identify potential complications if they arise.

Most feeding tubes are designed so the nutrients (usually a specifically designed formula) are deposited into the stomach where the body can digest them.  In situations where the patients feeding tube becomes dislodged or leaks, some of the formula can enter the abdominal cavity where the body has no way of processing it.  

When formula remains in the abdominal cavity for extended periods, an infection may result.  If the infection is not identified early on, the patient may be at risk for the progression of the infection throughout the body known as sepsis.  Unlike most localized infections, sepsis is a very aggressive type of infection that must be treated with interveneous antibiotics or the body may shut down.

Related Nursing Homes Abuse Blog Entries:

Nursing Home Staff Must Pay Special Attention To Avoid Complications When Caring For Patients Dependent On Feeding Tubes

Feeding Tube Mishap Results In Patient Death & Large Nursing Home Fine

Failure To Keep Bed Elevated To Blame For Nursing Home Patient's Death From Aspiration Pneumonia

Improperly Placed Feeding Tube Results In Death Of Nursing Home Patient

Rather than delivering food and medication directly to the man's stomach, the tube was delivering the materials to his peritoneal cavity resulting in inflammation, respiratory failure, septic shock-- and ultimately the patients death.  As a consequence of this nursing error, California officials find The Orchard Post Acute Care facility $75,000.

For patients with swallowing difficulties or other medical complications, insertion of a feeding tube may be necessary in order for the patient to receive adequate nutrition and medication.  There are several different types of 'feeding tubes' that doctors may use depending on the patients needs. 

A gastrostomy tube is place through the skin and the stomach wall, directly into the stomach.  In order to make sure the gastrostomy tube remains in place--- and into the stomach-- some facilities mark the tube where it exits the stomach to ensure that it is not pulling out.  When a gastrostomy tube gets pulled out of the stomach, the patient risks serious complications.

Related:

Whittier nursing facility fined in patient death, sfexaminer.com August 17, 2011

Feeding Tube Mishap Results In Patient Death & Large Nursing Home Fine

Feeding Tubes May Be Over-Used In Dementia Patients

Nursing Home Staff Must Pay Special Attention To Avoid Complications When Caring For Patients Dependent On Feeding Tubes

The failure to follow basic doctor's orders is to blame in a recently filed wrogful death lawsuit filed by the family of a patient in a Florida Nursing Home.  William Foster's family claims that Miracle Hill at Miracle Hill Nursing and Rehabilitation Center was negligent when they ignored orders to keep the head of Mr. Foster's bed elevated.  The failure to elevate the bed resulted in Mr. Forster's feeding tube becoming backed up and filling his lungs with fluid.  Ten days later, Mr. Foster died from aspiration pneumonia.

Read more about this pending wrongful death lawsuit here.

Aspiration Pneumonia

Aspiration pneumonia occurs when you aspirate foreign matter (usually food or vomit) into your lungs. Elderly adults are particularly susceptible to aspiration pneumonia because they are more likely to suffer from predisposing factors (including illness or disease that compromises the ability to swallow) or they might be too weak to cough, which can let foreign material enter the windpipe, allowing bacteria to enter the lungs. This can result in severe lung infections, which can require hospitalization, especially in older adults who are already weak because of age, illness, or disease.

In order to prevent aspiration pneumonia, doctors may recommend several precautions including keeping the head of the patients bed elevated at a position of 30-45 degrees in order to prevent the patient from choking on the feeding liquid.

Related:

Feeding Tube Mishap Results In Patient Death & Large Nursing Home Fine

Dysphagia In Nursing Home Patients May Contribute To Medical Complications Such As: Choking, Pneumonia Or Death

Elderly Patients Are At Higher Risk For Developing Aspiration Pneumonia When Facilities Fail To Account For Patient Needs

Failure To Follow Doctor's Orders Results In The Choking Death Of Hospital Patient

Investigators from the department determined that the nursing home patient died from aspiration pneumonia after insertion of a feeding tube because the nasal feeding tube was incorrectly inserting into his lungs rather than his stomach.

As a result of this nursing error, a $100,000 fine was imposed against Hancock Park Rehabilitation primarily due to the staff's failure to check to follow protocols related to assuring proper feeding tube placement. 

"By providing nursing facilities it licenses with consequences for substantiated violations, CDPH strives to protect the health and safety of vulnerable individuals," according to a CDPH statement. "The citation process is part of CDPH's ongoing enforcement efforts to improve the quality of care for residents of the state's approximately 1,400 skilled nursing facilities."

Hancock Park Rehabilitation Center has a history of prior nursing violations.  In 2006 and 2008 the facility received multiple violation related to improper patient care. Read more about this feeding tube complication here.

Feeding Tubes In Nursing Home Patients

Feeding tubes may be necessary for patients who are unable to chew or swallow or food. Like all medical treatments, feeding the insertion and maintenance of feeding tubes requires the expertise of medical professionals. 

Nursing home patients with NG-Tube's (Nasogastric Tube, placed through nose) are particularly as risk for aspiration pneumonia.  Primarily due to the increase in feeding tube patients, the number of hospital admissions related to aspiration pneumonia has increased 76% from 1991 to 1996.

In order to minimize the chance of feeding tube complications, nursing home staff should take care to monitor the food given to residents who have difficulty swallowing. Generally, thicker, cooler liquids are easier to swallow. Thin liquids, including water, can be dangerous because they are difficult to control within the mouth. Straws can help a person swallow by limiting the amount of liquid that can be taken at a time and directing the liquid to the back of the mouth.

It is of utmost important that staff take the necessary time during feedings to minimize trauma to the patient and assure safety.

Related:

Nursing Home Staff Must Pay Special Attention To Avoid Complications When Caring For Patients Dependent On Feeding Tubes

Feeding Tubes May Be Over-Used In Dementia Patients

Elderly Patients Are At Higher Risk For Developing Aspiration Pneumonia When Facilities Fail To Account For Patient Needs

Failure To Follow Doctor's Orders Results In The Choking Death Of Hospital Patient

Feeding tube use amongst dementia patients is extremely common.  According to a Business Week article, more than one-third of dementia patients in nursing homes currently have feeding tubes, with the majority of those being inserted during an acute care-hospitalization.

One reason possible reason for the frequency in the insertion of feeding tubes during acute hospitalizations may be due to the fact that when dementia patients enter a new environment-- such as an acute-care hospital, they have a difficult time adjusting to the new environment and may not immediately eat.

"They often get very stressed out, have disruptive behavior, get medications to treat that behavior, which leads them to developing bed sores and problems with eating, which leads to having a feeding tube inserted," according to Teno. "Part of what we need to do is align the incentives to keep frail older dementia patients in the least restrictive setting that will provide the best medical care."

As an alternative to feeding tubes, some experts suggest 'spoon feeding' patients.  Using a spoon feeding method, a person literally feeds the person with a spoon at his or her own pace.  Some experts suggest that spoon feeding may not necessarily prolong the life of the individual, but it can improve the quality of it. 

Patients who have feeding tubes in a nursing home or hospital setting are at risk for a variety of medical complications including:

Gastroesophageal reflux caused from gastric juices being forced back into the esophagus can occur with feeding tubes because the tubes sometimes cause a delay in the emptying of the stomach. This means that a person has to have more frequent, smaller feedings.

Clogging: Most feeding tubes are very narrow, and commercial tube feeding formulas such as Ensure, are designed so that they will not clog the tube; they are not too thick and do not leave a residue. Most formulas are designed to have water added to them to ensure that the patient is receiving enough dietary water, and to further thin the formula for ease of use. Staff should flush the tube with water before and after feedings, or after medications have been administered through the tube.  The use of noncommercial formulas is discouraged, because there is a greater likelihood that they will contribute to clogging. After the tube is placed, a registered dietitian or a nurse who specializes in nutrition should assess the patient to determine their nutritional needs, the amount of calories, protein, and fluids that will be necessary, as well as the most appropriate nutritional formula and how much of that formula will be needed each day. 

Nausea and vomiting is a common problem with feeding tubes. It occurs when liquid food is administered to an individual through a tube too quickly, or when the formula provided through the tube is too high in protein and/or calories. Migration (shifting) of the tube, bacterial infections and air in the stomach can cause nausea and vomiting as well.

Leakage is a complication of feeding tubes that occurs typically because the size of the stoma around the tube has increased, or because the position of the tube is improper due to bad placement or general shifting. This problem sometimes requires replacement of the tube, and it forces an individual or attending physician to keep the stoma clean with protective gauze and ointment.

Constipation occurs frequently with feeding tubes because the liquids that are administered through the tubes don't always have as much bulk or fiber as normal foods. Without fiber, an individual's digestive system has trouble retaining enough fluid and staying regular enough to produce frequent bowel movements. This problem means that the individual either has to find a way to introduce liquids that are higher in fiber through the tube (which can increase the risk of the tube clogging), or she has to take medications to relieve constipation.

Choking / Aspiration can occur if an individual is administered food through a feeding tube while in an improper position. This can result in choking, coughing and pneumonia. These, in turn, can aggravate the stoma, because the abdominal wall is forced to engage forcefully during a cough or sneeze. The aggravation of the stoma can lead to further infection. Most medical professionals suggest feeding patients when they are as up-right as possible to avoid aspiration on the food.

Many of these problems can be avoided when facilities employ adequate numbers of properly trained staff.  Consequently, if you have a loved one who require tube feeding, it is important to check with the facility to make sure they are accustomed to handling patients with these medical needs.

Resources:

Too Many With End-Stage Dementia Get Feeding Tubes, BusinessWeek, February 9, 2010

Common Complications of Tube Feeding

Nursing Home Staff Must Pay Special Attention To Avoid Complications When Caring For Patients Dependent On Feeding Tubes