Staff 9 admitted she mistakenly set Resident 2's feeding tube to deliver formula at 300 milliliters per hour during her shift on July 28. The physician had ordered the tube to run at 66 milliliters per hour for 18 hours daily, delivering a total of 1,206 milliliters of Jevity liquid nutrition.
The error went undetected for hours.
Staff 12 discovered the problem the next morning when she entered Resident 2's room during shift change. The feeding tube formula was bubbling out of the resident's tracheostomy site. An incident report dated July 29 documented her observation that the feeding pump was running at 300 milliliters per hour.
The mistake meant Resident 2 received more than four times the intended hourly dose of liquid nutrition through the feeding tube. Federal inspectors determined this placed residents at risk for complications related to feeding tube use.
Staff 12 told inspectors on October 1 that she found the feeding tube running at the incorrect rate after receiving report from Staff 9. She described seeing feeding tube formula bubbling out of Resident 2's tracheostomy opening.
Two days later, Staff 9 confirmed her error to inspectors. She stated she had left Resident 2's feeding tube running at approximately 300 milliliters per hour by mistake during her July 28 shift.
Staff 13, another licensed practical nurse, corroborated the account. She told inspectors that Staff 12 had found Resident 2's tube feeding running at 300 milliliters per hour on July 29.
The physician's order from July 18 specified precise parameters for the feeding. Resident 2 was to receive Jevity 1.5 formula at 66 milliliters per hour for 18 hours daily. The feeding was scheduled to run from 4:00 AM to 10:00 PM via pump.
Instead, the resident received formula at a rate that would have delivered the entire daily allowance in just four hours.
Staff 2, the director of nursing services, told inspectors on October 2 that she expected nurses to follow physician orders for feeding tubes. Her statement came more than two months after the incident occurred.
The facility's own incident report captured the immediate aftermath of the error. Staff discovered formula coming out of the resident's tracheostomy area, a clear sign that the feeding rate had overwhelmed the person's digestive system.
Tracheostomy sites are surgical openings in the throat that allow people to breathe when their upper airway is blocked or damaged. Formula bubbling out of this opening indicates the feeding tube contents had backed up significantly.
Federal inspectors reviewed three residents with feeding tubes as part of their complaint investigation. They found Evan Terrace Post Acute failed to provide appropriate feeding tube care for one of the three residents reviewed.
The inspection occurred in November, nearly four months after the July incident. Staff 9's admission that she made the error "by mistake" suggests the facility had not implemented adequate safeguards to prevent similar mistakes.
Feeding tubes deliver liquid nutrition directly to the stomach or small intestine for people who cannot eat or swallow safely. The prescribed rate ensures proper digestion and prevents complications like aspiration, where formula enters the lungs.
Running a feeding tube at 300 milliliters per hour instead of 66 represents a 354 percent increase in the delivery rate. This dramatic difference suggests a fundamental error in pump programming or calculation.
The July 29 incident report documented what Staff 12 observed, but inspectors found no evidence of immediate corrective action or investigation into how the error occurred.
Staff 9 worked an entire shift on July 28 without recognizing she had set the feeding rate incorrectly. The error persisted until the next nurse discovered it during morning rounds.
Resident 2's experience illustrates the vulnerability of people who depend on feeding tubes for nutrition. A single programming mistake by nursing staff can cause immediate physical distress and potential health complications.
The facility received a citation for failing to ensure residents received appropriate feeding tube care. Inspectors determined the violation caused minimal harm but created potential for actual harm to residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evan Terrace Post Acute from 2025-11-18 including all violations, facility responses, and corrective action plans.