Failure to Follow Tube Feeding Orders for Two Residents
Penalty
Summary
The facility failed to follow prescribed nutrition orders for two residents receiving tube feedings. For one resident with a history of protein calorie malnutrition and severe cognitive deficits, the tube feeding was not started at the ordered time. Observations showed that the tube feeding bag, which should have been replaced and restarted at 2 P.M., remained hung with formula from the previous day and was not turned on as ordered. Interviews with licensed nurses confirmed that the feeding was not administered according to the physician's orders, and the resident, who was NPO and dependent on tube feeding for nutrition, did not receive the required intake in a timely manner. For another resident diagnosed with malnutrition, dementia, and dysphagia, the tube feeding was observed to be running at a rate lower than the physician's order. The feeding was set at 50 ml/hr instead of the ordered 65 ml/hr. The responsible nurse acknowledged the error, and the Director of Nursing confirmed that staff should have ensured the feeding was administered at the correct rate. Both incidents were contrary to the facility's policy on enteral feeding safety precautions, which requires adherence to best practices in enteral nutrition.