Resident #5 received medication through a Duopa pump connected to a gastro-jejunal tube inserted in January. The system delivered medication for Parkinson's disease through narrow tubing much thinner than standard feeding tubes.
By June, parts of the tubing had broken down and passed through the resident's digestive system.
The gastroenterologist who installed the G-J tube said he typically recommends replacing the specialized tubing every six months. When inspectors told him that tubing pieces had passed through the resident's stool in June, he said the plastic tubing can become corroded over time.
"It was possible that the tubing could have started to breakdown," the doctor told inspectors on October 30.
Nobody at the facility had contacted any physician for guidance on maintaining the equipment when it wasn't actively delivering medication.
The neurologist's office said they only managed the pump tubing during active medication administration. Once the resident stopped receiving Duopa through the system, maintenance became the primary care physician's responsibility.
"They gave orders for flushing related to administration of the medication but once he was no longer using the pump, that would have been the PCP responsibility to monitor or give orders for maintenance," the neurologist's nurse explained to inspectors.
No one from Casa De Paz called to get clarification on continued flushing or maintenance while the pump sat unused.
The facility's own policy required clear direction for staff on feeding tube maintenance. According to the policy titled "Care and Treatment of Feeding Tubes," staff needed specific guidance on flushing frequency and volume, medication administration procedures, and replacement schedules.
The policy stated that direction must be provided regarding "the conditions and circumstances under which a tube was to be changed" and "when to replace and/or change a feeding tube."
Staff were supposed to receive instructions on when tubes should be replaced, "generally as ordered/scheduled by the physician when a long term feeding tube comes out unexpectedly, or when the tube was worn or clogged."
The gastroenterologist told inspectors he wasn't sure how long the narrow Duopa tubing would stay functional compared to regular feeding tubes. The specialized equipment required different maintenance protocols than standard tubes.
A nurse at the facility told inspectors that the company manufacturing the Duopa system sends trainers to teach nursing home staff how to use the equipment. But when asked about the flushing requirements that should have prevented the breakdown, she said "that would be a question for the neurologist who prescribed it."
On October 30, the Director of Nursing and Administrator acknowledged that none of the doctors had taken responsibility for orders or directions on maintenance for the Duopa pump tubing when it wasn't being used.
The equipment failure left the resident without a functioning medication delivery system. The deteriorated tubing pieces passing through his digestive system represented a complete breakdown of the specialized medical device.
The gastroenterologist's recommendation for six-month replacement cycles never reached the nursing staff. The neurologist's office limited their oversight to active medication periods. The primary care physician received no notification about the equipment requiring maintenance.
Casa De Paz's own policies demanded clear physician orders for tube replacement and maintenance schedules. But the facility operated the complex medical equipment without securing those essential orders from any doctor.
The Duopa pump system costs thousands of dollars and requires specialized training to operate safely. The narrow tubing that deteriorated inside Resident #5 carries medication directly into the small intestine, bypassing the stomach entirely.
When the plastic components began breaking down, nobody was monitoring the equipment's condition. The facility continued operating the system until tubing fragments emerged in the resident's stool months later.
The resident's medication delivery system had essentially disintegrated from the inside out while three different medical specialists assumed someone else was responsible for basic maintenance protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Casa De Paz Health Care Center from 2025-10-30 including all violations, facility responses, and corrective action plans.
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