Nurse #1 made the dangerous substitution on January 25 without a physician's order when Resident #1's jejunostomy tube — a surgically placed feeding tube that delivers nutrition directly into the small intestine — came out. The replacement catheter also became dislodged the same day, forcing the resident to undergo emergency surgery two days later.
The resident went to the operating room on the evening of January 27 to have the jejunostomy tube properly replaced. Federal inspectors found the nurse's actions created "a high likelihood of serious harm from the risks of placing the j-tube in the wrong place, perforation of the small intestine, sepsis, and bleeding due to anticoagulant use."
Nurse #1 had been hired by the facility just 15 days earlier as an agency licensed practical nurse. Her employee file contained no evidence of competency training regarding jejunostomy tubes.
During a phone interview on April 23, Nurse #1 told inspectors she was an experienced nurse who had completed training on feeding tubes at other facilities. But she could not recall completing specific jejunostomy tube training during orientation at Autumn Care.
The Director of Nursing acknowledged that the facility's orientation for agency nurses did not include specific competency training for jejunostomy tubes when Nurse #1 was employed in January.
Beyond the catheter incident, Nurse #1 made multiple other serious errors on January 25. She administered 2 units of sliding scale insulin to Resident #4, a diabetic patient whose blood sugar was 103. The physician's order specified no insulin coverage for blood sugar levels below 150.
Nurse #1 told inspectors she knew the resident didn't need insulin after checking his blood sugar in the "low 90s or 100s." She even told the resident's family members in his room that he wouldn't need the sliding scale insulin. But after returning to the medication cart, three nurse aides approached her with problems, distracting her.
"She then drew up 2 units of insulin and administered it to Resident #4," the inspection report states. "Once she administered the insulin the family stated they thought he didn't need insulin, and she realized then that he wasn't supposed to get the 2 units that she had just administered."
The nurse documented on the medication administration record that she had given "0 (zero) units" of insulin, falsifying the record. During the phone interview, she admitted: "If she documented 0 units administered then it was signed in error because she did give 2 units of insulin at 11:00 AM on 1/25/25."
Nurse #1 also failed to complete required documentation for Resident #1's transfer to the hospital. She left a four-page SBAR communication form largely blank, omitting critical information including the resident's primary diagnosis, medication alerts, vital signs, and comprehensive evaluations of his mental, functional, respiratory, cardiovascular, and neurological status.
The Director of Nursing tried repeatedly to get Nurse #1 to return to complete the paperwork, but she never came back to the facility.
The same nurse falsely documented that she had administered four medications to Resident #1 through his jejunostomy tube on the morning of January 25 — the same day the tube became dislodged. The medications included Eliquis (a blood thinner), Loratadine, Amlodipine, and Cetirizine.
During her interview, Nurse #1 admitted she had not actually given the medications. "She stated that she must have checked the medications off on the MAR as administered when she pulled them from the medication cart, but she did not administer the medications."
The facility's problems extended beyond Nurse #1's actions. Staff failed to follow proper laboratory procedures for Resident #3, who was experiencing burning, urgency, and decreased urinary output — symptoms of a urinary tract infection.
On April 15, a physician ordered a urinalysis and culture to evaluate the suspected infection and started the resident on antibiotics. Nurse #4 collected the urine sample through catheterization that day and entered the order into the electronic medical record and lab services website.
But the sample sat in the facility's refrigerator for more than a week. Nurse #4 failed to record the order in the lab book that the collection company uses to determine what specimens need pickup.
The Unit Manager discovered the oversight on April 23, eight days after the sample was collected. "The breakdown was that the order was not entered into the lab book therefore the lab did not pick up the urine sample," she told inspectors. "It was done in error."
The Nurse Practitioner found the sample still in the refrigerator and told inspectors they "did not get the lab results back and then discovered on 4/23/25 that the urine sample was still in the refrigerator in the facility and was never picked up by lab services."
Resident #3 continued experiencing mild symptoms but refused to be catheterized again. The physician treating him said she expected "lab orders to be entered correctly, and results made available and that was not done."
Inspectors also found infection control violations. Two nurses provided high-risk care to residents with tracheostomies and feeding tubes without wearing required protective gowns, despite clear Enhanced Barrier Precautions signs posted outside patient rooms.
Nurse #2 performed tracheostomy suctioning and administered tube feeding to Resident #2 while wearing only gloves and a mask. The blue sign outside the resident's room specifically required gowns for "device care or use" including "feeding tubes, tracheostomy."
When confronted, Nurse #2 told inspectors she "was unaware she was supposed to be wearing a protective gown while performing procedures involving tracheostomy and tube feeding care."
Nurse #3 made the same error while providing tracheostomy care to Resident #5. A supply cart with gowns and gloves was positioned directly outside the resident's room, but she failed to use a gown during the procedure.
"She stated it was done in error," Nurse #3 told inspectors after being observed.
The Assistant Director of Nursing, who also served as Infection Control Preventionist, had worked at the facility for only six months. She told inspectors she had received specialized infection control training just "a couple of weeks ago" and that nursing staff had been educated "multiple times in the last 6 months" on Enhanced Barrier Precautions.
Federal inspectors declared immediate jeopardy on April 23 due to the jejunostomy tube incident. The facility's corrective action plan was validated on April 24, with staff completing mandatory education and competency testing on feeding tube protocols.
The resident who underwent emergency surgery after the catheter incident was discharged from the facility on March 28, two months after the dangerous tube replacement. During his remaining time at Autumn Care, inspectors noted, "the j-tube did not dislodge again."
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Autumn Care of Myrtle Grove from 2025-04-24 including all violations, facility responses, and corrective action plans.
