Failure to Implement Dietitian-Recommended Tube Feeding Order
Penalty
Summary
A resident with a gastrostomy tube was observed to have their tube feeding pump set at an infusion rate of 55 ml per hour with a total volume of 1100 ml, despite a dietitian's recommendation to increase the rate to 60 ml per hour and a total volume of 1200 ml to address undesirable weight loss. The resident's medical record contained two conflicting tube feeding orders, both starting on the same date, one for 55 ml/hr and one for 60 ml/hr. The medication administration record and progress notes indicated that the resident consistently received the lower rate and volume over several days. During review, a registered nurse identified the discrepancy between the orders and acknowledged the need for clarification from the dietitian, confirming that only one order should be active. The dietitian confirmed her recommendation for the higher rate and volume to maintain the resident's weight. The resident's care plan required tube feeding to be administered as ordered, and facility policy directed staff to verify feeding orders. The failure to update and implement the dietitian's recommended tube feeding order resulted in the resident not receiving the prescribed nutritional support.