Failure to Provide Adequate Enteral Feeding Management
Penalty
Summary
The facility failed to ensure that a resident with an enteral feeding tube received appropriate treatment and services. The resident, who had diagnoses of anemia, Alzheimer's Disease, and hyperlipidemia, experienced significant weight loss over several months. Despite the weight loss, there was no documentation of assessment by the Registered Dietitian in September, October, November, and December 2024, nor were there any nutritional recommendations documented in the clinical record. The resident's weight loss was significant, with a 9.12% loss in one month and a 15% loss over three months. The facility's records showed a decrease in the tube feeding formula rate without supporting documentation for the change. The Registered Dietitian was not employed at the facility during a critical period and was only notified of the weight loss in November. The resident's husband, who dictated most of her care, refused to increase the tube feeding rate, but this refusal was not documented in the clinical record. The physician was not informed of the resident's weight loss until November 1st, despite the weight loss being evident in October. A verbal order to change the tube feeding formula was given, but the change was delayed until December 12th due to the need to use up the existing supply. The facility's failure to act promptly and document appropriately contributed to the deficiency in providing adequate care for the resident with an enteral feeding tube.
Plan Of Correction
Resident R36 is on the ordered tube feeding. There are no other tube feed residents presently in the building. Education being completed to nursing by the dietician or designee on orders for tube feedings being updated when recommended and ordered as well as weight loss monitored and nutritional assessment completed with weight loss. Education will include changing the feeding immediately when ordered and available. A QAPI will be completed to ensure weight loss and nutritional assessments completed by the dietician or designee. Weekly for one month, bi-weekly for one month and weekly thereafter. All results will be reported at to the QA committee.