Failure to Adhere to NPO Orders for Resident with PEG Tube
Penalty
Summary
The facility failed to ensure that a resident who was not able to eat by mouth (NPO) did not receive oral feedings. This deficiency affected one resident who had severe cognitive impairment and was dependent on staff for all activities of daily living. The resident had a PEG feeding tube and was not supposed to be on a mechanically altered or therapeutic diet. However, upon admission, the resident was started on a regular diet with regular texture and thin liquids without verifying with the physician whether the resident should be NPO. This led to the resident being fed orally by staff, which resulted in coughing or choking episodes. The medical record review revealed that the resident was admitted with multiple diagnoses, including acute respiratory failure with hypoxia and food in the respiratory tract. Despite these conditions, the initial physician orders did not include a diet order, and a regular diet was started without proper verification. A subsequent physician order confirmed the resident should be NPO, but the facility failed to adhere to this order. Interviews with staff confirmed the oversight, and the facility was unable to provide a policy for verifying diet orders, contributing to the deficiency.