Failure to Follow Professional Standards in Enteral Nutrition and Medication Documentation
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice for a resident receiving enteral nutrition. Specifically, a review of the resident's electronic health record revealed a physician order for enteral feeding with Jevity 1.2 at 70ml/hr over 18 hours, with water to run concurrently at 60ml/hr and tube flushes of 50ml pre and post feeding. However, during observation, the tube feeding pump was set to deliver water flushes at 50ml/hr instead of the ordered 60ml/hr. Staff confirmed that the pump settings did not match the physician's order, indicating a failure to verify and implement the correct settings at the beginning of the shift. Additionally, the facility did not document the administration of several medications for the same resident, as evidenced by blank entries in the Medication Administration Record (MAR) for multiple prescribed medications, including Pro-Stat Liquid, Amoxicillin-Pot Clavulanate, Guaifenesin ER, and Gabapentin Oral Solution. Staff interviews confirmed that it was the expectation for nurses to review physician orders, verify pump settings, and document medication administration, but these actions were not completed as required.