Failure to Provide Ordered Volume of Tube Feeding Nutrition
Penalty
Summary
Facility staff failed to ensure that a resident who required tube feeding received the full volume of artificial nutrition as ordered by the physician. The resident, admitted for care after a stroke and with swallowing difficulties, had a physician order for 1440 CC of liquid nutrition to be administered via feeding tube over an 18-hour period each day. Review of the Medication Administration Record (MAR) revealed that on multiple days, the resident received less than the ordered amount, with discrepancies ranging from 105 CC to 241 CC below the prescribed volume. The MAR did not provide a place to document the daily total of nutrition provided or the amount remaining at the end of each feeding cycle. Observations confirmed that the feeding pump was not always running as scheduled, and significant amounts of liquid nutrition remained in the bag at the end of the feeding period. Staff interviews indicated a lack of clarity regarding documentation of daily totals and remaining nutrition, and staff were not certain if this information was being monitored. The facility's policy required documentation of the amount and type of feeding provided, but this was not consistently done, resulting in the resident not receiving the full prescribed nutrition.