The incident occurred on the night of August 17, 2025, at Legacy Nursing at St. Christina. Federal inspectors found the feeding equipment sitting unused in the resident's room the following morning, with 1000 milliliters of Glucerna nutrition formula and water hanging from a pole beside the bed.
The resident, identified as #3 in the inspection report, has lived at the facility since 2021 with multiple conditions including cerebral palsy, dysphagia, and diabetes. The patient requires a feeding tube for adequate nutrition due to swallowing difficulties and has severely impaired cognition with a score of 2 on the facility's cognitive assessment.
Physician orders specified that the resident should receive continuous tube feeding from 7 p.m. to 7 a.m. at 60 milliliters per hour, along with water flushes every four hours during overnight hours. The resident also receives two bolus feedings during daytime hours.
When inspectors arrived at 9:38 a.m. on August 18, they found the feeding bag dated from midnight but completely disconnected from the resident. The feeding pump was turned off.
The day shift nurse told inspectors she had started her shift at 6 a.m. and had not yet entered the resident's room. She confirmed that the resident should receive continuous overnight feedings along with the two daytime bolus feedings.
The night nurse, identified as S3 LPN, admitted she had entered the resident's room between 7:15 and 7:30 p.m. but could not remember if feeding equipment was already hanging. She said she gave the resident a bolus feeding at 3 a.m. and hung the Glucerna and water bags with tubing around that time.
But the nurse acknowledged she "may have missed the order for continuous feeding to be administered overnight." She confirmed she had read the physician orders but failed to connect the feeding tube or start the pump for the continuous overnight nutrition.
The resident's care plan specifically states: "I require a PEG tube for adequate nutritional intake related to my dysphagia. Administer my tube feeding as ordered by my physician."
The facility's own policy requires that "all enteral tube feedings shall have care according to physician orders." The policy defines enteral feeding as providing "liquid nourishment through a tube, inserted into the stomach."
The Director of Nursing confirmed during an afternoon interview that the resident should have received the ordered continuous feeding on the night of August 17 but did not.
The resident has a complex medical history requiring careful nutritional management. Admitted originally in September 2021 and readmitted in July 2024, the patient has diagnoses including mild protein calorie malnutrition alongside the cerebral palsy and swallowing difficulties.
Current physician orders show the resident typically receives Glucerna 1.5 formula through the feeding tube overnight, with additional bolus feedings at noon and 4 p.m., followed by water flushes. There are also orders for additional feedings if the resident requests extra nutrition.
The night nurse denied that the resident had refused any feedings, indicating the missed nutrition was due to staff oversight rather than patient preference.
This type of feeding tube failure can have serious consequences for residents who depend entirely on tube nutrition due to their inability to swallow safely. The resident's existing diagnosis of mild protein calorie malnutrition makes consistent feeding particularly important.
Federal inspectors classified the violation as having minimal harm or potential for actual harm, affecting few residents. However, the incident highlights gaps in the facility's execution of basic nutritional care for its most vulnerable patients.
The inspection was conducted in response to a complaint, though the report does not specify the nature of the original complaint that triggered the federal review.
For a resident with severe cognitive impairment who cannot advocate for themselves or communicate hunger, missing an entire night's worth of ordered nutrition represents a fundamental failure of care coordination between nursing shifts.
The facility has policies in place requiring proper tube feeding administration, but the execution fell short when the night nurse hung the equipment but failed to complete the most critical step of actually connecting it to the patient who needed it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Legacy Nursing At St. Christina from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Legacy Nursing At St. Christina
- Browse all LA nursing home inspections