This CMS F-Tag governs nursing facility requirements for enteral (tube) feeding, including nasogastric and gastrostomy tubes. Facilities must ensure enteral feeding is clinically indicated and consented to by the resident or representative, and must provide appropriate care and services to restore oral eating skills where possible and prevent complications such as aspiration pneumonia, dehydration, and metabolic abnormalities. Facilities are required to develop and implement policies and procedures—developed with the medical director—covering tube monitoring, care, replacement, nutritional management, and complication management.
View official sourceF693
(Rev. 229; Issued: 04-25-25; Effective: 04-25-25; Implementation: 04-28-25)
§483.25(g) Assisted nutrition and hydration.
(Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic
gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a
resident's comprehensive assessment, the facility must ensure that a resident—
§483.25(g)(4)-(5) Enteral Nutrition
§483.25(g)(4) A resident who has been able to eat enough alone or with assistance is
not fed by enteral methods unless the resident’s clinical condition demonstrates that
enteral feeding was clinically indicated and consented to by the resident; and
§483.25(g)(5) A resident who is fed by enteral means receives the appropriate
treatment and services to restore, if possible, oral eating skills and to prevent
complications of enteral feeding including but not limited to aspiration pneumonia,
diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal
ulcers.
DEFINITIONS §483.25(g)(4)-(5)
“Bolus feeding” is the administration of a limited volume of enteral formula over brief
periods of time.
“Continuous feeding” is the uninterrupted administration of enteral formula over
extended periods of time.
“Enteral feeding” (also referred to as “tube feeding”) is the delivery of nutrients through
a feeding tube directly into the stomach, duodenum, or jejunum.
“Feeding tube” refers to a medical device used to provide liquid nourishment, fluids,
and medications by bypassing oral intake. There are two basic categories, naso-grastric
and gastrostomy. The type of feeding tube used must be based on clinical assessment and
needs of the resident since there are various kinds of feeding tubes within each category.
“Gastrostomy tube” ("G-tube") is a tube that is placed directly into the stomach through
an abdominal wall incision for administration of food, fluids, and medications. The most
common type is a percutaneous endoscopic gastrostomy (PEG) tube
“Jejunostomy tube” (a.k.a. “percutaneous endoscopic jejunostomy” (PEJ or “J-tube”) is
a feeding tube placed directly into the small intestine.
“Naso-gastric feeding tube” ("NG tube") is a tube that is passed through the nose and
down through the nasopharynx and esophagus into the stomach.
“Transgastric jejunal feeding tube” (“G-J tube”) is a feeding tube that is placed
through the stomach into the jejunum and that has dual ports to access both the stomach
and the small intestine.
GUIDANCE §483.25(g)(4)-(5)
A decision to use a feeding tube has a major impact on a resident and his or her quality of
life. It is important that any decision regarding the use of a feeding tube be based on the
resident’s clinical condition and wishes, as well as applicable federal and state laws and
regulations for decision making about life-sustaining treatments
CONSIDERATIONS REGARDING THE USE OF FEEDING TUBES
The regulations at §483.25(g)(4) require that a feeding tube is not used unless there is a
valid, clinical rationale, and the resident or if applicable, his/her representative has
consented to its use. Consent implies that a discussion has occurred between the resident
or representative and the physician, or other member of the treatment team, explaining
the process of receiving the tube, and the risks and benefits.
Several factors may be involved in the decision to use a feeding tube including medical
conditions that impair the resident’s ability to maintain appropriate nutritional parameters
(e.g., cerebrovascular accident, esophageal cancer, delirium, reconstructive facial or oral
surgery). The need to improve the resident’s nutritional status or level of comfort are also
factors that may be involved in the decision to use a feeding tube. The duration of use of
a feeding tube may vary, depending on the clinical situation and resident choice.
The interdisciplinary team, with support and guidance from the physician, is responsible
for assuring the ongoing review, evaluation and decision-making regarding the
continuation or discontinuation of all treatments, devices or approaches implemented to
care for the resident. Involving the resident, family, and/or the resident’s representative
in discussions about the indications, use, potential benefits and risks of tube feeding,
types of approaches, and alternatives helps support the resident’s right to make an
informed decision to use or not use artificial nutrition and hydration.
A clinically pertinent rationale for using a feeding tube includes, but is not limited to:
• An assessment of the resident’s nutritional status, which may include usual food
and fluid intake, pertinent laboratory values, appetite, and usual weight and
weight changes;
• An assessment of the resident’s clinical status, which may include the ability to
chew, swallow, and digest food and fluid; underlying conditions affecting those
abilities (e.g., coma, stroke, esophageal stricture, potentially correctable
malnutrition that cannot be improved sufficiently by oral intake alone); factors
affecting appetite and intake (e.g., medications known to affect appetite, taste, or
nutrition utilization); and prognosis;
• Relevant functional and psychosocial factors (e.g., inability to sufficiently feed
self, stroke or neurological injury that results in loss of appetite, psychosis that
prevents eating); and
• Interventions attempted prior to the decision to use a feeding tube and the
resident’s response to them.
The use of a feeding tube may potentially benefit or may adversely affect a resident’s
clinical condition and/or psychosocial well-being. Examples of some possible benefits of
using a feeding tube may include:
• Addressing malnutrition and dehydration;
• Promoting wound healing; and
• Allowing the resident to gain strength, receive appropriate interventions that may
help restore the resident’s ability to eat and, perhaps, return to oral feeding.
Examples of some possible adverse effects of using a feeding tube may include:
• Diminishing socialization, including, but not limited to, the close human contact
associated with being assisted to eat or being with others at mealtimes;
• Not having the opportunity to experience the taste, texture, and chewing of foods;
• Causing tube-associated complications; and
• Reducing the freedom of movement related to efforts to prevent the resident from
pulling on the tube or other requirements related to the tube or the tube feeding.
In order to assure that the resident being fed by a feeding tube maintains the highest
degree of quality of life possible, it is important to minimize possible social isolation or
negative psychosocial impact to the degree possible (e.g., continuing to engage in
appropriate activities, socializing in the dining room). Because of the possible side-
effects and discomfort associated with the use of nasogastric tubes, there should be
clinically pertinent documentation for extended use of nasogastric tubes (e.g., greater
than 30 days).
Nutrition and feeding issues and their underlying causes in the resident with advanced
dementia or other chronic neurological disorders such as Parkinson’s disease present a
particular set of issues and considerations that are discussed in F692. The extended use of
enteral feeding tubes in individuals with advanced dementia does not necessarily extend
life and remains controversial. The literature regarding enteral feeding of these
individuals suggests that there is little evidence that enteral feeding improves clinical
outcomes (e.g., prevents aspiration or reduces mortality).
CONSENT
A feeding tube should not be placed unless consented to by the resident or if applicable,
appropriately authorized resident representative. The resident has the right to make an
informed decision about the treatment they receive. If a resident had a feeding tube
placed prior to admission or in another care setting the physician and interdisciplinary
care team must review the basis (e.g., precipitating illness or condition change) for the
initial placement of the feeding tube and the resident’s current condition. This is to
determine if there is a continued rationale for its use and to ensure that its continued use
is consistent with the resident's treatment goals and wishes. Decisions to continue or
discontinue the use of a feeding tube are made through collaboration between the resident
(or a representative for a resident who lacks capacity to make and communicate such
decisions), the physician, and the interdisciplinary care team. This includes a discussion
of the relevance of a feeding tube to attaining a resident’s goals (e.g., whether the
nutritional intervention is likely to have a significant impact on the individual’s
underlying condition or overall status).
TECHNICAL AND NUTRITIONAL ASPECTS OF FEEDING TUBES
It is important that staff providing care and services to the resident who has a feeding
tube are aware of, competent in, and utilize facility protocols regarding feeding tube
nutrition and care. These protocols are required to be developed with the medical
director in order to assure staff implement and provide care and services according to
resident needs and professional standards of practice.
Facility policies and procedures regarding the technical aspects of feeding tubes must be
developed and implemented, which address:
Monitoring the feeding tube
How to verify that the tube is functioning before beginning a feeding and before
administering medications, which may include:
• Checking gastric residual volume (GRV)
o Not recommended for individuals who are alert and able to report symptoms
that indicate a feeding is not well tolerated.
o May be appropriate when initiating tube feedings or for individuals who are
unable to report symptoms such as bloating, nausea, or abdominal pain.
o Actions to take based upon the amount of GRV vary depending on the
individual and the clinical condition.
o pH of GRV may indicate correct placement i.e. pH < 5 generally indicates
gastric contents versus intestinal contents but medications and feeding
formulas can alter pH levels.
o Changes in GRV appearance may also be helpful in confirming placement but
should not be used in isolation.
o
• Observing changes in external length of tubing may indicate a change in position
but can only be used if the exit site was marked upon initial placement; this
method does not apply to low profile G tubes (tube that sits at skin level).
NOTE: Auscultation is no longer recommended for checking placement of the feeding
tube. Movement of air would likely be heard whether the tube was in the correct or
incorrect location. X-ray confirmation is the most accurate method for verification of
tube placement when concerns arise regarding dislodgement or placement. Additional
information regarding monitoring of feeding tubes may be found at,
https://www.ismp.org/tools/articles/ASPEN.pdf
NOTE: References to non-CMS/HHS sources or sites on the Internet included above or
later in this document are provided as a services and do not constitute or imply
endorsement of these organizations or their programs by CMS or the U.S. Department of
Health and Human Services. CMS is not responsible for the content of pages found at
these sites. URL addresses were current at the date of this publication.
Care of the feeding tube
• Securing a feeding tube externally;
• Providing needed personal, skin, oral, and nasal care to the resident;
• Examining and cleaning the insertion site in order to identify, lessen or resolve
possible skin irritation and local infection;
• Using infection control precautions and related techniques to minimize the risk of
contamination; for example, in connecting the tube and the tube feeding; and
• Defining the frequency of and volume used for flushing, including flushing for
medication administration, and when a prescriber’s order does not specify.
Feeding tube replacement. Direction for staff regarding the conditions and
circumstances under which a tube is to be changed, such as:
• When to replace and/or change a feeding tube (generally replaced either as
planned/scheduled or as needed such as when a long-term feeding tube comes out
unexpectedly or a tube is worn or clogged);
• How and when to examine a feeding tube and the infusion plug to identify splits
or cracks that could produce leakage;
• Instances when a tube can be replaced within the facility and by whom;
• Instances when a tube must be replaced in another setting (e.g., hospital,
ambulatory surgery center); and
• Notification of the practitioner when the need for a tube change arises
unexpectedly.
Nutritional Aspects of Feeding Tubes
When a resident is receiving nutrition via a feeding tube, the practitioner and the
interdisciplinary team identify the resident’s nutritional needs and facility procedures that
direct staff in providing care and services to the resident. The practitioner’s orders related
to tube feeding typically include the following components: kind of feeding and its
caloric value; volume, duration, and mechanism of administration (e.g., gravity or pump);
and frequency of flush.
Facility procedures regarding the nutritional aspects of feeding tubes include, but are not
limited to:
Enteral nutrition. Direction to staff regarding the nutritional product and meeting the
resident’s nutritional needs such as:
• Types of enteral nutrition formulas available for use;
• How to determine whether the tube feedings meet the resident’s nutritional needs
and when to adjust them accordingly;
• How to balance essential nutritional support with efforts to minimize
complications related to the feeding tube;
• Ensuring that the selection and use of enteral nutrition is consistent with
manufacturer’s recommendations;
• Ensuring that the administration of enteral nutrition is consistent with and follows
the practitioner’s orders; and
• Ensuring that the product has not exceeded the expiration date;
• Ensuring that additional water ordered for flushes or for additional hydration is
administered per orders.
Flow of feeding. Direction for staff regarding how to manage and monitor the rate of
flow, such as:
• Use of gravity flow;
• Use of a pump;
• Periodic evaluation of the amount of feeding being administered for consistency
with practitioner’s orders;
• Calibration of enteral feeding pumps to ensure that pump settings accurately
provide the rate and volume consistent with the resident’s care plan; and
• Periodic maintenance of feeding pumps consistent with manufacturer’s
instructions to ensure proper mechanical functioning.
Complications Related to the Feeding Tube
An enteral feeding tube may be associated with significant complications, including
aspiration, leaking around the insertion site, abdominal wall abscess, or erosion at the
insertion site including the nasal areas. Feeding tubes can perforate the stomach or small
intestine, with resultant peritonitis. Esophageal complications of feeding tubes may also
occur including esophagitis, ulcerations, strictures, and tracheoesophageal fistulas. The
use of tubes not designed or intended for enteral feeding may increase the risk of
complications.
16, 17
Tubes may clog for various reasons, including plugging by formula, pill fragments, or the
precipitation of medications incompatible with the formula.
18 Flushing feeding tubes
regularly and in association with medication administration, as indicated by current
professional standards of practice and provided in the resident care policies, can help
reduce the risk of clogging.
Complications Related to the Administration of the Enteral Nutrition Product
The administration of an enteral nutrition product may be associated with other
complications including, but not limited to, nausea, vomiting, diarrhea, abdominal
cramping, inadequate nutrition and aspiration. Additionally, interactions between the
formula and various medications can affect the absorption and/or effectiveness of the
medication. For example, the effectiveness of phenytoin sodium (Dilantin, Phenytek)
may be reduced by the drug binding with the enteral feeding's protein component, leading
to less free drug availability and possibly inadequate therapeutic levels.
Metabolic complications related to tube feeding may include inadequate calorie or
protein intake, altered hydration, hypo- or hyperglycemia, and altered electrolyte and
nutrient levels. These risks may be reduced by calculating the nutritional needs of the
resident, taking into account comorbid conditions and medications that affect these
balances, monitoring for adequate nutritional status and complications, and adjusting the
tube feeding accordingly.
While a feeding tube may be initiated with the intent to address certain medical
conditions, the use of a feeding tube does not necessarily decrease the risk of aspiration
for individuals with other risk factors, such as moderate or less severe swallowing
abnormalities. Aspiration risk may potentially be affected by factors such as diminished
level of consciousness, improper positioning of the resident during administration of the
feeding, and failure to assure the feeding tube is correctly positioned within the stomach
or intestine. The evidence is inconsistent and conflicting regarding any connection
between gastric residual volume (GRV) and the risk or occurrence of aspiration.
19
Risk of aspiration should be assessed individually and appropriate interventions (e.g.,
proper positioning, rate of flow) implemented accordingly. There may be situations
where other coexisting factors influence decisions about elevating the head of the bed; for
example, a resident being fed by a tube who may be at risk for shearing by sliding down
the sheets when the head of the bed is elevated to a recommended angle.
Complications Management
The facility is expected to identify and address actual or potential complications related
to the feeding tube or tube feeding and to notify and involve the practitioner in evaluating
and managing care to address these complications and risk factors.
PROCEDURES §483.25(g)(4)-(5)
Use the Tube Feeding Critical Element (CE) Pathway along with the above guidance
when determining if the facility utilized a feeding tube only after adequate assessment of
the resident’s clinical condition to ensure this intervention is medically necessary and
with the resident’s consent.
The surveyor(s) should use the following: observations, interviews and record reviews to
determine if a feeding tube is utilized only if the resident’s clinical condition makes this
intervention medically necessary and with the resident’s consent. The surveyor must
determine if a feeding tube is utilized in accordance with current professional standards
of practice and if services are provided to prevent complications to the extent possible.
Additionally, for a resident whose goal is to restore normal eating skills to the extent
possible, the surveyor must determine if the necessary care and services were provided to
reach this goal. If there are concerns regarding the facility’s use and care of feeding
tubes, review facility policies and practices with regard to the use and care of feeding
tubes.
NOTE: In addition to actual or potential physical harm, always observe for visual cues
of psychosocial distress and consider whether psychosocial harm has occurred when
determining severity level (See guidance on Severity and Scope Levels and Psychosocial
Outcome Severity Guide located in the Survey Resources zip file located at
https://www.cms.gov/medicare/provider-enrollment-and-
certification/guidanceforlawsandregulations/nursing-homes).
KEY ELEMENTS OF NONCOMPLIANCE
To cite deficient practice at F693, the surveyor's investigation will generally show that
the facility failed to do one or more of the following:
• Ensure enteral feeding was clinically indicated; or
• Ensure enteral feeding was consented to by the resident; or
• Ensure a resident receiving enteral feeding received appropriate care and services
to restore oral eating skills, if possible, or
• Ensure a resident receiving enteral feeding received appropriate care and services
to prevent complications of enteral feeding.
DEFICIENCY CATEGORIZATION
An example of Severity Level 4 Noncompliance : Immediate Jeopardy to Resident
Health or Safety, includes but is not limited to:
• The facility failed to properly set up the tube feeding pump and to monitor a
cognitively impaired resident receiving the tube feeding, resulting in the resident
receiving too much liquid nourishment at a rate too fast to be absorbed. The
resident was found to be unresponsive with excess liquid nourishment coming
from his or her nose and mouth.
An example of Severity Level 3 Considerations: Actual Harm that is Not Immediate
Jeopardy includes, but is not limited to:
• The facility failed to monitor for complications related to a resident’s feeding tube
and tube feeding. As a result, the resident experienced significant but not serious
tube feeding-related complications; or
Examples of Severity Level 2 Noncompliance: No Actual Harm with Potential for
More than Minimal Harm that is Not Immediate Jeopardy includes, but is not
limited to:
• As a result of staff failure to anchor a feeding tube properly, the resident had
leakage and irritation around the tube insertion site that required topical treatment
and resolved without complications;
• As a result of staff failure to manage a tube feeding pump properly, the resident
did not receive the calculated amount of tube feeding, without resulting in
significant weight loss or other GI complications; or
• As a result of staff failure to consistently flush a resident’s feeding tube as
ordered, the tube clogged and had to be replaced, but there were no other
complications.
Severity Level 1: No Actual Harm with Potential for Minimal Harm
The failure of the facility to provide appropriate care and services for feeding tubes,
places the resident at risk for more than minimal harm. Therefore, Severity Level 1 does
not apply for this regulatory requirement.
POTENTIAL TAGS FOR ADDITIONAL INVESTIGATION
If there are concerns identified regarding the resident receiving adequate
nutrition/hydration when receiving tube feeding, review F692, Assisted Nutrition and
Hydration, for further investigation.
If there is lack of consent related to the placement of a feeding tube, cite those
deficiencies here instead of the Resident Rights since this regulatory language is specific
to consent for a feeding tube.