Failure to Follow Physician's Feeding Order
Penalty
Summary
The facility failed to follow the physician's order for the administration of feeding for a resident who was dependent on tube feeding for nutrition and hydration. The resident, who had severe malnutrition and a history of weight loss, was supposed to receive a continuous feeding of Jevity 1.5 at 85 milliliters per hour for 12 hours daily, along with a bolus feeding of 237 milliliters at 5:00 PM. However, observations revealed that the resident was receiving the continuous feeding at a rate of 80 milliliters per hour, resulting in a significant shortfall in the total volume of Jevity administered. This discrepancy was due to the nurse on duty not checking the updated order and not being informed of the change during the shift report. The resident's care plan indicated a risk for malnutrition due to inadequate oral intake, and the resident often refused the bolus feedings. The Registered Dietitian had recommended increasing the rate of Jevity to compensate for the resident's poor oral intake and difficulty swallowing. Despite these recommendations, the facility did not ensure the correct administration of the feeding order, as evidenced by the nurse's failure to verify the updated order and the lack of communication during shift changes. Observations also noted the resident's dry mouth, which was acknowledged by staff but not adequately addressed in terms of hydration management.
Plan Of Correction
(1) What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? On 4.4.25 resident #31 was assessed by licensed nurse, no concerns identified. On 4.4.25 staff C nurse was provided 1:1 education by Assistant Director of Nursing on following physician orders for the administration of feeding. (2) How you will identify other residents having potential to be affected by the same practice and what corrective actions will be taken; On 4.11.25 a quality review was completed by Director of Nursing/designee on current residents receiving nutrition to ensure appropriate formula in place and rate reflective of physician orders. Any issues identified were corrected. (3) What measures will be put into place or what systematic changes you will make to ensure that the practice does not recur; On 4.22.25 education completed with current licensed nursing staff on the components of F693 management with an emphasis on ensuring accurate formula administered at rate per physician orders by the Director of Nursing/designee. Newly hired licensed nursing staff will be educated on the components of F693 management with an emphasis on ensuring accurate formula administered at rate per physician orders by the Assistant Director of Nursing/Designee during orientation as part of the systematic change. (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: Director of Nursing/Designee to conduct audits of 5 residents with nutrition twice a week for 4 weeks, then once a week for 4 weeks and then monthly for 1 month to ensure accurate formula administered at rate per physician orders. The findings of these quality monitorings to be reported to the Quality Assurance/Performance Improvement Committee monthly until the committee determines substantial compliance has been met.