Failure to Follow Enteral Nutrition Orders and Notify DPOA
Penalty
Summary
The facility failed to adhere to a physician's order for enteral nutrition for Resident #95, who was observed with an incorrect infusion rate of 50 mL/hour instead of the prescribed 60 mL/hour. This discrepancy was noted on 4/8/2025, despite the physician's order being updated on 4/1/2025. The nurse responsible for Resident #95 was unaware of the change in the infusion rate, and the error was not corrected until later in the day when the rate was temporarily increased to compensate for the missed volume. Additionally, the facility did not notify Resident #95's Durable Power of Attorney (DPOA) about the change in the tube feed rate from 50 mL/hour to 60 mL/hour. The resident's daughters, who are frequently present at the facility, were not informed of this change or the temporary increase in the infusion rate to make up for the missed volume. This lack of communication with the resident's responsible party was confirmed by both the daughters and the Registered Dietitian. Furthermore, there were no documented orders for the routine cleansing, assessment, and monitoring of Resident #95's PEG tube site following her readmission on 3/21/2025. The Clinical Care Coordinator and Corporate Nurse confirmed the absence of such orders, which are essential for maintaining the site. The facility's policy on medication administration emphasizes resolving any discrepancies before proceeding, yet this was not adhered to in the case of Resident #95.