Inaccurate Transcription and Documentation of GT Feeding Orders
Penalty
Summary
The facility failed to accurately transcribe and document a physician's order for gastrostomy tube (GT) feeding and water administration for one resident. The physician's order specified that the resident should receive Nutren tube feeding at 50 ml/hr and water at 40 ml/hr for 16 hours, but the order and the Medication Administration Record (MAR) both indicated a start time of 6 p.m. and a stop time of 6 a.m., which only covers 12 hours instead of the prescribed 16 hours. This discrepancy was present in the resident's medical record and persisted from the date of the order through the end of the month, with the MAR signed as if the order had been correctly carried out. The resident involved had significant medical conditions, including heart failure, chronic kidney disease, and dementia, and was totally dependent on activities of daily living with severe cognitive impairment. Both the registered dietitian and a licensed vocational nurse confirmed during interviews and record reviews that the GT feeding and water flush should have been administered over 16 hours, from 6 p.m. to 10 a.m., and agreed that the documentation was incorrect. The facility's policy required that medical records be complete and accurate, but this was not followed in this instance.