Failure to Administer Enteral Nutrition and Hydration as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of metabolic encephalopathy, diabetes, obesity, and dysphagia, who was dependent on enteral nutrition, did not receive tube feedings and water flushes as ordered by the physician. Multiple observations over two days showed the resident's feeding pump was consistently set at 45 ml/hr for Glucerna 1.5 and 30 ml/hr for water flush, instead of the physician-ordered 60 ml/hr for Glucerna 1.5 and 55 ml/hr for water. The resident's medical records and dietary notes confirmed the prescribed rates, which were intended to meet the resident's full nutritional and hydration needs due to their NPO status and risk for malnutrition. Staff interviews revealed that nursing staff were unaware of the correct settings and did not verify or clarify the physician's orders when discrepancies were noted. The LPN acknowledged the error after checking the orders, and the Unit Manager was not informed of any changes. Even after the feeding rate was corrected, the water flush remained incorrect. The facility's policy required verification and adherence to physician orders for enteral feedings, which was not followed in this instance.