Failure to Administer Tube Feeding as Ordered
Penalty
Summary
A deficiency occurred when a resident with severe protein-calorie malnutrition, adult failure to thrive, and gastrostomy status did not receive tube feedings as ordered by the physician. The resident's care plan required tube feedings to meet nutritional and hydration needs, with a physician order specifying continuous administration of formula at 65 ml per hour for 19 hours daily via gastrostomy tube. On observation, the feeding pump was not running, and the tubing was not connected to the resident, with 900 ml of formula remaining in the bag that was supposed to start at 6:00 AM. The resident's private attendant was not present at the time of observation. Nurse interviews revealed that the tube feeding was not consistently administered as ordered, with the nurse stating she was unaware of the specific tube feeding orders and had only intermittently started and stopped the feeding based on the resident's and attendant's requests. The Registered Dietitian confirmed that the resident had not received the required amount of formula for the observed period, and noted a history of the private attendant turning off the feeding pump. The DON stated that the nurse should have ensured the tube feeding was running as ordered and acknowledged the history of the attendant interfering with the feeding process.