Resident D depends entirely on tube feeding because of dysphagia, a condition that makes swallowing dangerous. More than half of their nutrition comes through a gastrostomy tube surgically placed in their stomach.
The resident's physician ordered water flushes of 50 milliliters per hour on June 23. But when federal inspectors checked the feeding pump on August 27, it was set to deliver 60 mL per hour instead.
Two different nurses confirmed the incorrect setting during separate observations that afternoon. At 1:50 p.m., Registered Nurse 2 pushed the button on the feeding pump to display the flush rate. The machine showed 60 mL per hour. At 4:13 p.m., Nurse 3 repeated the same check with the same result.
Neither nurse corrected the setting during the inspection.
Resident D's medical record shows a complex case requiring precise care. The resident has muscle weakness, diabetes, and the gastrostomy tube that delivers both nutrition and hydration. A care plan from April indicates complete dependence on staff for tube feeding and water flushes.
The facility's own policy, revised in August 2024, requires staff to follow physician orders exactly for feeding tube care, including "frequency of and volume for flushing."
Water flushes serve critical functions for feeding tube patients. They prevent the tube from clogging, deliver necessary hydration, and help medications flow properly through the system. Too little water can cause dangerous blockages. Too much can dilute nutrition or overwhelm a patient's system.
For Resident D, who receives continuous tube feeding at 65 mL per hour, the extra 10 mL of water per hour represents a 20 percent increase over the prescribed amount. Over a 24-hour period, that means an additional 240 mL of fluid beyond what the physician determined appropriate.
The inspection occurred in response to a complaint filed with state regulators. Federal investigators reviewed three residents with feeding tubes but found the dosing error affected only Resident D.
A quarterly assessment from June shows Resident D's condition requires ongoing tube feeding support. The care plan initiated in April acknowledges the resident cannot safely swallow and depends on staff to operate the feeding equipment correctly.
The feeding pump malfunction went undetected despite multiple nursing shifts checking on the resident. The facility's medication administration records would have shown the discrepancy if nurses had been comparing pump settings to physician orders during their rounds.
State inspectors classified the violation as causing minimal harm or potential for actual harm. But feeding tube errors can escalate quickly, particularly for residents with diabetes like Resident D, where fluid balance affects blood sugar control.
The facility has operated feeding tube patients under its revised policy since August 2024, which explicitly states that tubes "would be utilized according to physician orders and direction for staff to provide care to the feeding tube."
During the inspection, nursing staff demonstrated they knew how to check pump settings by pushing the display button. They confirmed the incorrect 60 mL rate twice but took no action to correct it to match the physician's 50 mL order.
Resident D continues to depend on the feeding tube for survival, requiring nursing staff to follow precise medical orders for both nutrition delivery and water flushes. The resident's muscle weakness and swallowing disorder make accurate tube feeding care essential for preventing complications.
The violation occurred despite the facility's written policy requiring adherence to physician orders and the presence of experienced nursing staff who understood how to operate the feeding equipment. The error persisted until federal inspectors discovered it during their August inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brickyard Healthcare - Brookview Care Center from 2025-08-28 including all violations, facility responses, and corrective action plans.
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