Failure to Administer Prescribed Enteral Nutrition Due to Pump Malfunction
Penalty
Summary
Facility staff failed to administer the prescribed amount of enteral nutrition to a resident with multiple complex medical conditions, including diabetes mellitus, chronic obstructive pulmonary disease, cerebrovascular disease, gastrostomy, hypertension, and dysphagia. The resident was totally dependent on staff for all activities of daily living and had severe cognitive impairment. The physician's order specified that the resident should receive diabetic source enteral feeding at 1.2 calories per milliliter, 80 ml per hour for 20 hours, totaling 1600 ml or 1920 calories, with a scheduled pause from 8 am to 12 pm. Observation at the resident's bedside revealed that the enteral feeding pump was turned off, and only 200 ml of formula had been infused over a 12-hour period, instead of the ordered 960 ml. The feeding bottle had been hung the previous evening, and the discrepancy was confirmed during an interview with the DON, who acknowledged the resident did not receive the required nutrition due to the pump not functioning as intended. The facility's policy required adequate nutritional support through enteral nutrition as ordered, but this was not followed in this instance.