Allure of Pinecrest Cited After Director of Nursing Replaces Resident’s Urinary Catheter Feeding Tube, Tube Later Migrates into Small Intestine Causing Bowel Obstruction and Pancreatitis

The Illinois Department of Health has cited and fined Allure of Pinecrest in Mount Morris, Illinois when, according to state investigators and facility records, the Director of Nursing replaced a urinary catheter that was being used as a temporary feeding tube without consulting the physician about the replacement, without a facility policy specifically governing the procedure, without measuring or marking the tube length, and without documented certification or competency records to perform the procedure. The tube subsequently migrated into the resident’s small intestine, causing a partial bowel obstruction and pancreatitis that required hospitalization.

The resident had originally been admitted to the facility with a surgically placed feeding tube. After she pulled the tube out, she was sent to the local emergency room. Because no surgical team was available at that time, the emergency room inserted a urinary catheter to function as a temporary feeding tube and sent her back to the facility. The hospital’s discharge instructions were specific: the temporary tube needed to be replaced with a longer-term feeding tube by a general surgeon within one to two weeks, staff should check the guide mark on the tube where it meets the skin (which should not change), and staff should use tape or an anchoring device to keep the tube from getting pulled on. The family requested to wait for a swallow study before pursuing the permanent replacement.

Several weeks later, the resident’s husband requested that the temporary urinary catheter feeding tube be changed. According to the Director of Nursing’s account, she changed the catheter herself based on her experience from a previous facility — without speaking to the physician and without a facility policy specifically governing the procedure. She later told investigators she considered it a routine procedure performed under a standing order. She replaced the original 16 French catheter with a 20 French catheter, again without consulting the physician. She acknowledged in her interview that she did not mark or measure the tubing where it entered the resident’s abdomen, and she only “recalled approximately 12 inches or so of tubing extending out.” She acknowledged she had no certification — only hands-on training from her previous employer — and confirmed that the facility did not have any policy or procedure for changing this type of tube.

The day after the replacement, staff reported the tube was leaking. The Director of Nursing assessed it and said it seemed okay. The next day a nurse called her and reported the tube was leaking to the point of soaking the bed. The Director of Nursing told the nurse to send the resident to the emergency room. By the time the resident reached the hospital, the only part of the catheter still visible outside her body was the tip. Hospital imaging confirmed the tube had migrated into the proximal jejunum — the upper part of her small intestine. The catheter was causing a partial bowel obstruction and substantial leakage from the stoma site. The resident’s lab work was consistent with pancreatitis. A gastroenterologist successfully replaced the tube with a standard feeding tube, and the resident was treated with intravenous fluids and medications for pancreatitis.

The resident’s physician told investigators he did not recall speaking to staff about changing out the urinary catheter feeding tube and that this is typically something done in the emergency room by a doctor. He stated that on an emergency basis a nurse might place the tube back but the patient would still be sent to the emergency room to confirm correct placement. He told investigators directly that the feeding tube migrating into the jejunum could cause a blockage of the bile duct, which in turn could lead to pancreatitis.

Multiple nurses interviewed by investigators stated they had received no education or training on the use of a urinary catheter as a feeding tube. One nurse said the morning she came on shift and found the catheter flush against the resident’s stomach with feeding all over the resident and the bed, it was the first time she had ever seen a urinary catheter used as a feeding tube. The Administrator acknowledged that no in-service was done for nurses on this type of tube. The facility’s own policy on feeding tubes required licensed nurses to monitor that the tube is in the right location and to check the device daily to assure proper placement — but the policy did not define how staff were to do this, and there was no policy at all for replacing a urinary catheter feeding tube.

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