An improperly inserted nasal feeding tube was the cause of an 84-year-old's death in a California Nursing Home according to an investigation completed by the California Department of Health.  

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