Failure to Administer Ordered Enteral Nutrition via G-Tube
Penalty
Summary
The facility failed to provide enteral nutrition as ordered for one resident who was dependent on tube feeding for nutritional support. The resident, who had multiple diagnoses including cancer, dementia, and was assessed as rarely or never understood, had physician orders for Jevity 1.5 to be administered via G-tube at 60 ml/hr for a total of 1200 ml over 20 hours daily. Observations revealed that the tube feeding was not initiated in the morning as ordered, with no supplement present in the resident's room during multiple checks. Staff interviews confirmed that the tube feeding was routinely stopped after the 1200 ml was infused, and not restarted until the next scheduled session, rather than running continuously for the prescribed 20 hours. Further review showed that the resident did not receive the full volume of enteral nutrition as ordered, as the feeding was not started until the afternoon and was not supplemented to meet the total daily requirement. Staff acknowledged that the feeding was paused for ADL care but did not adjust the schedule to ensure the resident received the full prescribed amount. These actions resulted in the resident not receiving nutrition via enteral method as ordered, constituting a failure to follow physician orders and provide appropriate care for a resident with a feeding tube.