Federal inspectors responding to a complaint found that Resident 8 had a percutaneous endoscopic gastrostomy tube inserted directly into their stomach on July 25, 2024. When they arrived at the nursing home on August 12, the thin, flexible tube was already in place to deliver nutrition and medications.
But no orders existed for monitoring or flushing the PEG tube.
The resident went without the required care until August 19 — seven days after admission — when staff finally added orders to flush the tube with 5 to 10 milliliters of water twice daily. The orders also required daily inspection of the surrounding skin for redness, swelling, irritation or signs of infection, plus daily tube site care and syringe changes.
No documentation existed showing the tube had been flushed or monitored during that week-long gap.
Unit Manager 14 told inspectors on October 28 that she would have expected PEG tube orders immediately upon admission. Those orders should include monitoring the insertion site for infection and providing water flushes, she said.
The resident could eat and drink by mouth, so the PEG tube wasn't being used for feeding. But that didn't eliminate the need for maintenance care.
"She confirmed water flushes would still be expected to be completed in residents that are not currently receiving tube feeding," inspectors wrote. The unit manager said she would have expected Resident 8 to receive water flushes much sooner than when they were finally ordered.
Director of Nursing confirmed the facility had failed its own protocols. She told inspectors the nursing home maintained an order set that staff could have entered immediately upon the resident's admission. That order set would have included both monitoring the tube placement site and providing the maintenance flushing.
The inspection followed a complaint filed on October 27 reporting that daily flushes were not being completed for the resident's PEG tube.
PEG tubes require consistent maintenance to prevent dangerous complications. Without regular flushing, the tubes can become blocked with medication residue or feeding formula, requiring emergency replacement procedures. Stagnant fluid in unflushed tubes creates breeding grounds for bacteria that can cause serious infections.
The skin around the insertion site also requires daily monitoring. Infections at PEG tube sites can spread rapidly in elderly patients, potentially leading to sepsis or requiring surgical removal of the tube.
Even when patients can eat by mouth, their PEG tubes need maintenance care. Many residents keep feeding tubes as backup access for medications or nutrition during illness, making proper maintenance critical for their safety.
The nursing home's own protocols recognized these risks. Both the unit manager and director of nursing acknowledged that proper orders should have been in place from the moment Resident 8 arrived with the feeding tube.
Instead, the resident spent their first week at the facility without the basic care their medical device required. The complaint that triggered the federal inspection suggests the problem may have continued even after orders were finally entered.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm to few residents. But the case illustrates how administrative failures in nursing homes can leave vulnerable residents without essential medical care.
The facility had the proper order sets available. Staff knew the requirements. The director of nursing confirmed the protocols existed.
Resident 8 simply fell through the cracks during their first week at Autumn Lake Healthcare at Baltimore Washington, their feeding tube left without the daily maintenance that prevents blockages and infections.
Full Inspection Report
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