Failure to Administer Correct Enteral Feeding Amount
Penalty
Summary
The facility failed to ensure that a resident receiving Enteral g-tube feeding was administered the correct amount of feeding as per the physician's orders. On March 31, 2025, a resident was observed with their Enteral g-tube feeding machine turned off and not connected, despite the feeding bottle being dated for that day. The Licensed Practical Nurse (LPN) on duty was unaware of who turned off the machine or for how long it had been off. The resident, who is alert and talkative, was supposed to receive continuous feeding at a rate of 70 ml/hr for 20 hours, but only 100 ml had been infused over a four-hour period, instead of the expected 280 ml. The resident involved has multiple diagnoses, including severe protein-calorie malnutrition and quadriplegia, and relies entirely on tube feeding for nutrition. The Director of Nursing (DON) confirmed that the feeding should have been running according to the physician's orders and that the resident should have received the full amount of feeding to meet their caloric needs. The facility's policy and job descriptions emphasize the importance of maintaining proper nutrition and hydration through tube feeding, yet the deficiency occurred due to a lapse in following these procedures.