Failure to Provide Continuous Tube Feeding per Physician Order
Penalty
Summary
A deficiency occurred when a resident with a history of traumatic brain injury and quadriplegia, who was unable to participate in mental status exams and required a feeding tube, did not receive enteral nutrition as ordered by the physician. The physician's order specified continuous tube feeding at 85cc/hr for 24 hours, with no order to hold or stop the feeding. Facility policy also required continuous feeding, only to be stopped for medication administration and routine flushes. However, observations revealed that the resident's tube feeding pump was off and the formula was not connected for nearly three hours, during which the resident was not receiving the prescribed nutrition. Interviews with staff indicated that the tube feeding should have been running continuously, and there was no documented physician order to stop the feeding. The DON stated that she wanted to hold the feeding due to increased oral secretions but admitted she did not obtain or transcribe a physician's order to do so. This failure to follow physician orders and facility policy resulted in the resident not receiving enteral nutrition as prescribed.