Failure to Follow Physician Orders for Enteral Nutrition
Penalty
Summary
The facility failed to follow physician orders regarding the administration of enteral nutrition for a resident diagnosed with unspecified protein-calorie malnutrition and chronic respiratory failure. The resident was admitted with a tracheostomy and a PEG tube, with a physician's order specifying continuous tube feeding of Nutren 1.5 at 60 mL/hour for 20 hours per day, totaling 1200 mL. Review of the medication administration record showed significant discrepancies in the actual volumes administered on multiple days, with amounts ranging from 60 mL to 3405 mL, deviating from the prescribed total. A licensed nurse confirmed that the tube feeding order was not being documented correctly, indicating a failure to ensure the physician's order was followed.