Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to ensure that residents with feeding tubes received the appropriate treatment and services as ordered by the physician, leading to potential complications. For Resident #39, the facility did not administer the prescribed amount of enteral feeding. Observations revealed that the resident's tube feeding was not consistently running as ordered, and the nursing staff did not hang the required amount of formula to meet the resident's nutritional needs. Interviews with nursing staff indicated confusion regarding the feeding order, and it was noted that the resident was not receiving the full 1600 milliliters of formula as prescribed, which was necessary to meet their caloric and protein requirements for wound healing. Resident #147 also did not receive the prescribed enteral feeding as ordered. Observations showed that the resident's feeding tube was not connected, and the formula bag was not replaced as scheduled. The Medication Administration Record lacked documentation of the volume infused, and interviews with nursing staff revealed that the formula bag was not checked or replaced during the evening shift. This oversight resulted in the resident not receiving the necessary nutrition from the enteral feeding. The facility's policies and procedures for enteral feedings and physician orders were not followed, leading to these deficiencies. Nursing staff were unaware of the volume of formula in the bottles and did not adhere to the prescribed feeding schedules. The Director of Nursing and Registered Dietician confirmed that the residents were not receiving the feeding according to the provider's orders, which compromised their nutritional intake.
Plan Of Correction
Plan of Correction: Approved March 11, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensed Nurses assigned to residents #39 & 147 on days cited in the SOD were counseled regarding administration of tube feedings and correct documentation. Resident #39 was assessed by medical provider; no adverse effect was noted due to not receiving tube feeding. Resident #147 was assessed by medical provider; no adverse effect was noted due to not receiving tube feeding. A review of physician orders [REDACTED]. #39 and 147 were completed by the RD with no issues noted. A full house review of residents receiving tube feedings was performed to ensure that tube feeding is administered per MD order and that administration record has documentation of administrations; no other areas of concern were identified. The Enteral Feeding Policy was reviewed by the Director Of Clinical Services with no revisions required. All licensed nurses will be reeducated by the RN Educator, in conjunction with RD, regarding tube feed administration, how to utilize feeding pump(s), rechecking for accuracy and correct documentation of tube feeding administered. RN Educator/Designee will conduct weekly Tube Feeding audits of all residents receiving tube feedings x 8 weeks to ensure tube feed was administered, infusing correctly and documented correctly per provider’s order. Issues noted will be immediately addressed. Audit findings will be reported to the QAPI committee Monthly for review. Responsible Person: DON