Failure to Administer Enteral Nutrition as Ordered
Penalty
Summary
A deficiency was identified when a resident with a history of brain injury, seizure disorder, and quadriplegia, who was dependent on staff for activities of daily living and unable to express needs, did not receive enteral nutrition as ordered by the physician. The physician's order specified that Jevity 1.2 should be administered at a rate of 55 ml per hour starting at 8:00 p.m. until a total of 935 ml was infused. However, observation revealed that the tube feeding was not connected to the resident, the pump was turned off, and only 300 ml had been infused by the following morning. Staff interviews confirmed that the tube feeding had been stopped for care and was not resumed according to the physician's order. The LPN on duty stated that the tube feeding was typically started on the night shift and continued until early afternoon, but had not disconnected the feed during her shift. The Director of Nursing verified that the feeding had not been restarted as required, resulting in the resident not receiving the prescribed amount of nutrition.