Failure to Follow Nutritional Recommendations for Enteral Feeding
Penalty
Summary
The facility failed to maintain acceptable nutritional parameters for a resident receiving enteral nutrition, as evidenced by a lack of adherence to the recommendations provided by the Registered Dietitian. Resident R33, who was admitted with conditions including pleural effusion, muscle weakness, dysphagia, and cognitive communication deficit, required tube feeding due to difficulty swallowing. The care plan indicated that the Registered Dietitian was to evaluate the resident's nutritional needs quarterly and as needed, making recommendations for changes to the tube feeding regimen. Despite the Registered Dietitian's recommendation on January 2, 2025, for the tube feed to run at 65 ml/hour over 22 hours for a total volume of 1430 ml daily, the facility did not follow this guidance promptly. The clinical record showed a series of physician orders adjusting the tube feed rate, but there was no documented rationale from the physician for the delay in meeting the resident's caloric needs as recommended. This oversight resulted in the facility's failure to ensure the resident received the appropriate treatment and services to maintain nutritional parameters.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident R148 tube feeding orders were reviewed with physician to updated to reflect current needs. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken: An audit will be conducted for current Residents to ensure that all tube feeding orders are current and are being followed. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur: Education will be provided by the DON/ and or designee to nursing staff regarding the components of this regulation. (4) How the corrective action(s) will be monitored to ensure the practice will not recur, i.e., what quality assurance program will be put in place: Random audits will be conducted weekly by the DON/ and or designee of five residents to ensure that tube feeding orders updated and are being followed. Audits will be conducted weekly x for four weeks and then monthly for six months. Results of these audits will be reported to the monthly Quality Assurance Performance Improvement Committee until monthly and/or substantial compliance is met. Adjustments to the plan of corrections will be made by the Interdisciplinary team as needed.