Failure to Follow Physician Orders for Enteral Feeding
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders for a resident receiving enteral feedings. The resident, who had a history of stroke affecting her dominant side, cognitive communication deficit, dysphagia, and required gastrostomy feedings, was admitted with orders to receive Osmolite 1.5 at 100cc/hr for 12 hours nightly, with Jevity 1.5 to be used only if Osmolite was unavailable. Clinical record review confirmed these orders, and facility policy required staff to verify and follow physician orders for enteral feedings. During observations on two consecutive mornings, the resident was found to be receiving Jevity 1.5, despite Osmolite being available in the facility. This was confirmed in an interview with the Nursing Home Administrator, who acknowledged that the facility did not follow the physician's order. The deficiency was cited under relevant Pennsylvania Codes for management, resident care policies, and nursing services.