Failure to Administer Tube Feeding per Complete Physician Order and Accurate Documentation
Penalty
Summary
The facility failed to ensure that tube feeding was administered to a resident according to physician orders and that a complete physician order was in place prior to administration. One resident with a diagnosis of dysphagia following cerebral infarction had a tube feeding order that, prior to being updated, did not specify the type of formula to be administered. Staff confirmed that the resident had been receiving tube feeding since admission, but the order was incomplete until it was updated. The interim Director of Nursing acknowledged that the previous order lacked essential details, such as the formula type, which is necessary for safe administration. Additionally, on one occasion, a Licensed Practical Nurse documented that the resident received tube feeding when, in fact, the feeding was not administered as ordered. The nurse prepared the feeding and documented its completion before actually providing it, then failed to return to administer the feeding after the resident requested a short delay. The nurse did not document the resident's refusal or the missed administration. The facility's policy and the nurse's job description both require accurate documentation and adherence to physician orders for tube feeding, which were not followed in this instance.