CROWN POINT, IN - Federal inspectors documented serious feeding tube care failures at Crown Point Christian Village that prevented residents from receiving critical medications and water flushes.
G-Tube Malfunction Delays Critical Care
On August 13, 2024, a Licensed Practical Nurse discovered she couldn't disconnect a feeding line from a resident's gastrostomy tube (g-tube) during the morning medication round between 9:00 and 9:30 a.m. The nurse was unable to administer morning medications or required water flushes due to the equipment malfunction.
Multiple nursing staff members, including the wound nurse, Assistant Director of Nursing (ADON), and Unit Manager attempted to separate the feeding line without success. The resident wasn't sent to the hospital until after 2:30 p.m., more than five hours after the problem was first identified.
Delayed Notifications Compound Problem
The inspection revealed significant communication breakdowns during the incident. The ADON and Unit Manager weren't notified about the feeding tube malfunction until 1:50 p.m., despite the morning medication round occurring hours earlier.
The attending physician wasn't contacted until after 2:30 p.m., and family members only learned about the situation when they arrived at the facility that afternoon. According to facility policy, both physicians and family members should be notified immediately when there's a change in status requiring significant treatment alterations.
Medication Administration Failures
Inspectors identified patterns of medication non-administration beyond the g-tube incident. A resident with iron deficiency anemia had pharmacy bottles showing medications weren't being given as prescribed.
One bottle of iron supplement (ferrous sulfate) delivered on June 20, 2024, remained three-quarters full by August 13, despite orders for twice-daily administration. At the prescribed dosage of seven cubic centimeters twice daily, the bottle should have been nearly empty after nearly two months.
Laboratory results showed the resident's red blood cell count and hemoglobin levels had declined over several months, from 11.4 to 9.3 hemoglobin between May and August 2024. Normal hemoglobin levels range from 14-18 grams per deciliter.
Basic Hygiene Requirements Overlooked
The facility failed to provide mandated bathing for residents dependent on staff assistance. Two residents didn't receive the required twice-weekly baths, with documentation showing multiple missed shower dates marked as "non-applicable" or left blank.
Federal regulations require nursing homes to ensure dependent residents receive bathing assistance at least twice weekly. Proper hygiene prevents skin breakdown, infections, and maintains resident dignity and comfort.
G-Tube Care Standards Violated
Beyond the equipment malfunction, inspectors found systemic g-tube care deficiencies affecting multiple residents. Staff failed to verify tube placement before medication administration, didn't flush tubes after each medication, and used improper labeling for feeding bags.
Proper g-tube care requires flushing with water before and after medications to prevent blockages and ensure medication delivery. Tubes must be checked for proper placement to prevent aspiration, where medications or formula enter the lungs instead of the stomach.
Medical Consequences of Care Lapses
These care failures pose serious health risks. Missed medications can worsen underlying conditions, particularly for residents with anemia who require consistent iron supplementation. Delayed treatment during g-tube malfunctions can lead to dehydration and medication gaps that compromise resident stability.
Improper feeding tube management increases risks of infection, aspiration pneumonia, and tube displacement. Water flushes prevent dangerous blockages that can require emergency intervention, as occurred in this case.
Regulatory Response
The Centers for Medicare & Medicaid Services cited Crown Point Christian Village for multiple violations during the August 14, 2024 inspection. The facility was found to have minimal harm or potential for actual harm affecting few residents across the documented deficiencies.
The violations included failure to provide appropriate treatment according to physician orders, inadequate assistance with activities of daily living, and improper feeding tube care management.
Crown Point Christian Village must submit a plan of correction addressing each identified deficiency to continue participating in Medicare and Medicaid programs. The facility is required to demonstrate how it will prevent similar incidents and ensure compliance with federal nursing home standards.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Crown Point Christian Village from 2024-08-14 including all violations, facility responses, and corrective action plans.
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