Incomplete Documentation of Tube Feeding Administration and Orders
Penalty
Summary
The facility failed to ensure that a resident's medical record was clear and complete regarding the administration of tube feeding (TF) formula. Specifically, licensed nurses did not consistently sign the Medication Administration Record (MAR) each time the TF formula was administered, resulting in incomplete documentation of the number of pouches given per day. Additionally, the physician's order summary and the MAR lacked critical information, such as the prescribed TF rate and the total number of pouches to be administered, despite the hospital discharge instructions specifying these details. A resident with a gastrostomy status was admitted with orders for TF that included specific instructions for preparation, dilution, and administration rate. However, the facility's documentation did not reflect the required TF rate or the total daily amount, and only one nurse signed the MAR daily, even though the TF was to be administered every eight hours. Interviews with nursing staff and the Director of Nursing confirmed these omissions and acknowledged that the records should have included complete orders and signatures for each administration to accurately track the care provided.