Resident 1 was admitted to Buena Park Nursing Center on October 8 with a specialized gastrojejunostomy tube, which has two separate ports. The J tube port delivers nutrition directly to the small intestine, bypassing the stomach entirely. The G tube port connects to the stomach and was attached to a drainage bag to remove gastric contents.
For patients with gastroparesis, this distinction is life-threatening. The condition prevents normal stomach emptying, so feeding through the G tube port causes nutrition to remain in the stomach rather than reaching the intestines for absorption.
Staff began feeding Resident 1 through the wrong port immediately upon admission.
Nurses notes from October 8 at 7:35 p.m. documented that "Resident 1 was started on feeding via J tube and G tube." This indicated staff were simultaneously feeding through both ports, despite physician orders specifying feeding should occur only through the J tube.
The error continued for seven days.
On October 15, Resident 1's blood glucose dropped to 36 mg/dl, a level that can cause seizures, coma, or death. Normal blood sugar ranges from 70 to 140 mg/dl. The facility's nurse practitioner could not explain what caused the dangerous drop during an October 30 interview with state inspectors.
Nobody caught the feeding error until October 24, when RN 2 told investigators that Resident 1 "was receiving feeding from his J tube port" and had "a drainage bag connected to his G tube port." This was the first documented recognition that the two ports served different functions.
The facility's Director of Nursing acknowledged during an October 30 interview that staff "should not assume and should have confirmed Resident 1's enteral feeding was being provided via J tube as ordered by the physician."
When inspectors asked what could happen if Resident 1 received feeding through the G tube, the director explained that "Resident 1 had gastroparesis, the feeding would stay in his stomach, and could cause discomfort, vomiting, hypoglycemia, and death."
The director admitted she never provided in-service training to staff before assigning them to care for residents with gastrojejunostomy tubes.
"The DON acknowledged she should have provided the in-service training and made sure the staff were competent to take care of the residents with a GJ tube," inspectors wrote.
Staff confusion extended beyond the feeding ports. The facility attached a drainage bag to Resident 1's G tube upon admission but never obtained a physician's order for the drainage bag or its management. Medical records contained no orders for how long the drainage should continue or when it should be discontinued.
On October 9, a nurse practitioner wrote an order to "d/c G tube draining," but this order lacked specificity about the drainage bag removal process. RN 3 told inspectors during an October 29 interview that "the G tube drainage bag required a physician's order and staff should have obtained the physician's order for the G tube drainage bag maintenance and discontinuation."
The nurse practitioner who treated Resident 1 told inspectors on October 30 that the resident was eventually transferred to an acute care hospital because "his J tube being clogged." The practitioner confirmed that Resident 1 "should have received his enteral feeding through the J tube as ordered by the physician, because of his gastroparesis."
When asked if he could confirm whether Resident 1's feeding was properly reaching the small intestine on October 15, the day of the blood sugar crisis, the nurse practitioner stated "he could not confirm."
The practitioner explained that if Resident 1 received feeding through the G tube port, "if Resident 1 was not having nausea and vomiting he would think the feeding was being passed down to the small intestine." This assumption-based approach highlighted the facility's lack of systematic monitoring for patients with complex medical devices.
During the week-long feeding error, Resident 1 likely received little to no nutrition despite regular feeding schedules. With gastroparesis preventing stomach emptying, formula delivered through the G tube would have remained in his stomach rather than providing nourishment. This explains the severe hypoglycemia that developed by October 15.
The case revealed broader systemic failures in staff competency and medical oversight. The Director of Nursing told inspectors that if staff couldn't identify the correct ports of a GJ tube, "they could always reach out to the doctor, clinical coordinator and herself." Yet staff never sought guidance during the seven-day period when they were feeding through both ports simultaneously.
Medical records review found no documentation of staff questioning the dual feeding approach or seeking clarification about the physician's orders. The facility's nurses notes from October 8 matter-of-factly recorded starting feeding through both the J tube and G tube, suggesting staff viewed this as routine procedure.
RN 2's October 24 telephone interview with inspectors marked the first time anyone at the facility clearly articulated that Resident 1 should receive feeding only through the J tube port while the G tube remained connected to drainage.
The administrator and Director of Nursing acknowledged the findings when informed by inspectors on October 30. State investigators classified the violation as causing "actual harm" to "few" residents, indicating Resident 1 suffered documented injury from the improper care.
Resident 1's hospitalization for the clogged J tube occurred after the feeding error was discovered, adding another layer of medical complexity to his care. The facility had not only fed him incorrectly for a week but also failed to maintain the proper functioning of his specialized medical equipment.
The case underscores the risks faced by nursing home residents who require complex medical devices. Without proper staff training and clear protocols, life-sustaining equipment can become life-threatening when misused.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Buena Park Nursing Center from 2025-10-30 including all violations, facility responses, and corrective action plans.