The Director of Nursing told inspectors on May 20 that staff "used to have a folder at the nurses' station with the policies but the staff couldn't find it yesterday when they looked for it." She confirmed that medication carts also lacked policies for nurses to follow.
The facility's written policy from December 2011 requires specific safety steps for administering medications through feeding tubes. Staff must crush all tablets and mix the powder with 15 to 30 milliliters of water. They must verify tube placement, check for gastric residual, and flush the tube with water before giving medications.
Each medication should be administered separately with water flushes between drugs. Staff must flush the feeding tube with at least 15 to 30 milliliters of water after completing all medications.
But confusion emerged about which safety steps were actually required.
The Corporate Nurse told inspectors that "checking placement/residual was not a requirement anymore." The Director of Nursing said that when Resident 35 first arrived, the physician indicated residual checks weren't required, "but she didn't have documentation to prove that."
Despite this uncertainty, the Director of Nursing told inspectors she expected staff to follow the facility policy regarding checking placement, residuals, and water flushes with medication administration.
The Corporate Nurse reported that all nursing homes in the corporation used the same feeding tube policies.
Staff training on feeding tube procedures appeared limited. The Director of Nursing said staff received verbal education about feeding tubes when Resident 35 first arrived at the facility. However, she admitted she "didn't think she documented anything" about this training.
The missing policies created a gap between written procedures and actual practice. While the facility maintained detailed requirements for safe feeding tube medication administration, nurses couldn't access these guidelines during their daily work.
Feeding tube medication administration carries significant risks when proper procedures aren't followed. Medications given incorrectly through feeding tubes can cause blockages, infections, or medication errors that harm residents.
The facility's own policy recognized these dangers by requiring multiple safety checks. Verifying tube placement prevents medications from going into the wrong location. Checking gastric residual helps ensure the stomach can handle additional fluids. Water flushes prevent medication buildup that could block the tube.
Federal inspectors found the facility violated requirements for medication administration safety. The violation received a minimal harm rating, affecting few residents.
The inspection revealed a facility where written safety policies existed but weren't readily available to the nurses responsible for following them. Staff received verbal training that wasn't documented, and corporate guidance contradicted facility policies about required safety checks.
For Resident 35 and other residents receiving medications through feeding tubes, this meant nurses were working without clear, accessible guidelines for critical safety procedures. The Director of Nursing's expectation that staff follow facility policy became difficult to enforce when the policy itself couldn't be located.
The Corporate Nurse's assertion that residual checks were no longer required directly conflicted with the facility's written December 2011 policy. This contradiction left nurses uncertain about which safety steps they should actually perform.
When inspectors asked basic questions about feeding tube policies and training documentation, facility leadership couldn't provide clear answers or locate essential safety guidelines. The missing policy folder represented more than a paperwork problem – it symbolized a breakdown in the systems designed to protect vulnerable residents who depend on feeding tubes for nutrition and medication delivery.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Stratford Specialty Care from 2025-05-21 including all violations, facility responses, and corrective action plans.