Failure to Thoroughly Investigate Tube Feeding Grievance
Penalty
Summary
The facility failed to thoroughly investigate a grievance regarding the administration of tube feeding formula for a resident who was ordered to receive 325 ml of formula within one hour at four specified times daily. The investigation did not consider the maximum rate of the facility's tube feeding pumps, which was 295 ml/hr, making it impossible to deliver the ordered amount within the specified time using the pump alone. Additionally, the facility did not identify that the physician's order was unclear and unachievable with the available equipment, nor did staff question or clarify the order despite its impracticality. During the investigation, staff did not measure the total amount of tube feeding in the enclosed bag before and after feedings, nor did they verify the amount of formula remaining after the third feeding session. This omission made it difficult to determine if the resident was receiving the prescribed amount. Observations confirmed that after three feedings, significantly more formula remained in the bag than expected, indicating the resident was not receiving the full ordered amount. Furthermore, staff were unaware that the tube feeding pumps had a plus/minus 10% error rate, which could result in under-delivery of the formula. The facility unilaterally declared the grievance resolved without providing follow-up or written notification to the complainant or ombudsman, as required by their own grievance policy. Documentation confirming communication of the investigation's outcome to the complainant and ombudsman was not provided. The lack of a thorough investigation and failure to address the complainant's concerns led to the issue being escalated to the state health department.