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F0684
D

Failure to Follow Physician's Orders for Enteral Feeding

Saint Augustine, Florida Survey Completed on 04-10-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when the facility failed to follow physician's orders regarding the administration of enteral feeding for a resident with severe protein-calorie malnutrition, dysphagia, and a gastrostomy tube. The physician's order specified that Jevity 1.5 should be administered via G-tube at 40 ml/hr, starting at 2:00 PM and stopping at 10:00 AM daily, with an autoflush every hour for four hours. However, during an observation at 12:10 PM, the enteral feeding was still infusing, contrary to the order to stop at 10:00 AM. Interviews with nursing staff, including an RN, an LPN/Nurse Manager, and the Director of Nursing, confirmed that the feeding should have been stopped at 10:00 AM as per the physician's order. The RN admitted to not paying attention to the time, resulting in the feeding continuing past the ordered stop time. The facility was unable to provide a policy and procedure for following physician's orders when requested during the survey.

See complete original report
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