Failure to Follow Tube Feeding Orders and Weight Policy
Penalty
Summary
The facility failed to adhere to physician's orders for tube feeding and its own policy regarding resident weights, resulting in weight loss for a resident with a feeding tube. The resident, who was readmitted with diagnoses including Type 2 Diabetes and severe cognitive impairment, had specific orders for Glucerna 1.5 tube feeding at 60 ml per hour for 20 hours daily. However, observations revealed inconsistencies in the administration of the tube feeding, with significant periods where the feeding was not running as ordered. This inconsistency in feeding led to the resident receiving only 18 hours of feeding per day, providing insufficient caloric intake compared to the resident's estimated needs. Additionally, the facility did not follow its policy for weighing residents, as no new readmission weight was recorded for the resident. The Registered Dietitian and Restorative Certified Nursing Assistants were responsible for managing and recording weights, but there was a lack of coordination and communication regarding the weekly and admission weights. This oversight contributed to the resident's weight loss, as evidenced by a recorded weight drop from 184.2 pounds to 176 pounds within a month, indicating a 4.45% weight loss.