Failure to Specify Enteral Feeding Formula in Physician's Order
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition had a physician's order specifying the type of feeding formula to be administered. Record reviews showed that the resident, a female with cerebral palsy, epilepsy, hypertension, and a gastrostomy, had orders and care plans for tube feeding, but none of these documents indicated the specific type of enteral formula required. Observations confirmed that a specific formula (Jevity 1.5 cal) was present in the resident's room, but staff interviews revealed that, due to the lack of specificity in the order, any type of formula could potentially be administered. Nursing staff acknowledged that this omission could result in the resident receiving an incorrect formula. Further interviews with the DON and Administrator confirmed that orders for enteral nutrition should specify the exact product to be used, and that the absence of this information placed the resident at risk of receiving the wrong feeding. The facility's own policy required that enteral nutrition orders be complete, including the product name, but this was not followed in the resident's case. The deficiency was identified through observation, record review, and staff interviews.