A city nursing home has been fined and might face further penalties for its role in a chain of events that led to an 89-year-old nursing home patient being tube fed until the food exploded from her and she was left to languish in pain for hours before being rushed to a hospital where she was pronounced dead.

The unidentified woman was a patient at Baltimore's Villa St. Michael Nursing and Retirement Center last month when she was tube fed more than eight times the amount of liquid food that her doctor had ordered, according to a state inspection report released yesterday in response to a request by The Sun.

Calling the incident "horrific and inexcusable," Carol Benner, director of the state Office of Health Care Quality, said the nursing home, at 4800 Seton Drive in Northwest Baltimore, is being assessed a fine of $7,500 and could face expulsion from state- and federally funded health care programs.

Although the patient was groaning in obvious distress, the state report said, nursing-home personnel not only continued the tube feeding but also waited more than five hours before making an emergency ambulance call. In the meantime, according to the report, the victim was engorged with feeding formula.

The formula "exploded from her mouth and nose. ... It was everywhere," the report said.

"It's atrocious and heartbreaking," said Benner, adding that the nursing home has been ordered to file a corrective action plan to show how it will prevent a similar incident from happening.

"She was dependent on the feeding tube to live, and she was dependent on the nursing home to look out for her. ... And this happened," she said.

Officials of the 200-bed nursing home did not respond yesterday to a request for comment. According to state records, the facility is owned by Philip Miller of Potomac and other members of his family. Miller has said that he is not responsible for the day-to-day operations of the facility.

Benner said the usual fine for a single event that causes harm to a patient is $5,000.

The fine was increased to $7,500 for Villa St. Michael because of the "egregiousness of the incident," she said, adding that the nursing home's history was also was a factor in raising the penalty.

Another case cited

In addition to the case of the 89-year-old woman, state inspectors also cited the home for failing to provide "comfort care" to an 89-year-old man who was rapidly deteriorating and gasping for breath.

The male patient died Nov. 10, two days after his labored breathing was first noted.

Charles Culberston, president of Seniors United, an advocacy group for senior citizens, said the amount of the fine being imposed by the state seemed inadequate, given the apparent degree of negligence.

The state inspection report detailing the incident provided a chronology of errors and misjudgments that led to the 89-year-old woman literally being fed to death.

According to the report, the patient was returned to the nursing home Nov. 15 after a surgeon fitted her with a feeding tube. The surgeon left orders that the feedings should not start until the next day.

"For some reason (no one could give the reason why this was done)," the report stated, a nurse later consulted the patient's attending physician about the feedings rather than the surgeon.

The attending physician, unaware of the surgeon's order, told the nurse to begin the feedings that day but at set doses and regular intervals ranging from four to 12 hours.

Although his instructions were followed for two feedings, the report stated that a night nurse resumed the feedings at about 11 p.m. and then inexplicably allowed the feed tube to continue running without interruption for the rest of the night, even replacing the bag when it ran out.

"The expectation would be for the nurse to realize that continuous tube feeding rates above 125 cubic centimeters were excessive and to question why the resident was receiving 275 cubic centimeters continuously," the report said.

State inspectors said that the feed tube continued to run even after the nurse heard a grunting sound from the patient at 2 a.m.

The report stated there was no indication the tube feeding was stopped, even after the patient's doctor had been consulted and ordered her transferred to a hospital.

No emergency call

Then, the report said, instead of placing an immediate emergency call for an ambulance, a nursing home employee called a private ambulance company that could not pick up the patient until 10 a.m.

By that time, the patient was moaning with pain, and her abdomen was distended.

Finally, the report stated, at 7 a.m. the day nurse arrived and went to the patient's room and found her "moaning and grunting with every breath. ... The day nurse informed the night nurse that the patient needed to be sent out 'now' and not at 10 a.m."

After the 911 call was placed, the day nurse reported that the patient went into cardiac arrest.

"When he turned her head to the side, formula exploded from her mouth and nose. ... It was everywhere," the report continued, adding that the nurse was unable to get oxygen to the patient's airways because each time he attempted to clear her throat, it filled up again with formula.

The patient was pronounced dead at a local hospital, the report said.