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14 Dead from Improper Tube Feeding

San Francisco, CA – At least 14 residents have died in the past 20 months from improper tube feeding in California nursing homes. Instead of providing food and liquids to those in need, improper tube feeding resulted in 23 incidents that were investigated and cited by the California Department of Health (DHS) during 2003-04. These incidents caused dehydration, hypertension, infection, respiratory and renal failure and the death of 14 residents.

California Advocates for Nursing Home Reform (CANHR) reviewed 23 feeding tube-related citations received from January 2003 through August 2004 and found that feeding tubes were improperly placed in the lungs, removed without the consent of residents or a doctor’s orders, or not inserted as ordered. Some tubes were not properly monitored for cleanliness or functioning resulting in infections, tube leakage and dislodgement.

One or more of these citations was issued the following counties:
Alameda (3), Amador (1), Contra Costa (3), Imperial (1), Los Angeles (2), Napa (1), Orange (3), San Bernardino (1), San Diego (2), San Francisco (1), Santa Clara (2), Solano (1), Stanislaus (1), Ventura (1).

Of the 23 citations studied:

  • 61% resulted in death
  • Only 4 Class AA citations were issued
  • Only 1 Class AA fine was for the maximum fine of $100,000
  • 9 citations were issued as Class A
  • None of the Class A citations was for the maximum fine of $20,000
  • 10 citations (including four in which deaths occurred) were issued as class “B”, which carry fines of no more than $1,000
  • All showed a lack of skill or attention on the part of licensed staff

Note: Tube feeding is a method of providing nutrition to people who cannot sufficiently obtain calories by eating or to those who cannot eat because they have difficulty swallowing. Tubes, which transport nutritional formulas, can be inserted into the stomach (G-tubes or PEG tubes – Percutaneous EndoGastric tubes), through the nose and into the stomach (NG-tubes), or through the nose and into the small intestine (NJ tubes). The NG and NJ tubes are considered to be temporary and the G tube is considered more permanent, but it can be removed. Feeding tubes that are not properly placed or maintained can cause liquids to enter into the lungs instead of the stomach, thereby increasing the risk of pneumonia or respiratory failure.

Download the citation summaries (PDF)