Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to ensure that tube feeding was administered as ordered for a resident with multiple comorbidities, including protein calorie malnutrition, COPD, chronic kidney disease, stroke, and dysphagia. The resident was admitted with severe cognitive impairment and was totally dependent on staff for daily care, including eating. Physician orders and the care plan specified that the resident was to receive Jevity 1.5 at 60 cc per hour for 20 hours, totaling 1200 cc and 1800 kcal, to be administered via enteral pump starting at 2 pm until the total volume was delivered. During observation, the enteral pump was found to be inactive and alarming, with only 166 ml of tube feeding administered, far less than the ordered amount. Staff did not respond to the pump's alarm or address the discrepancy when it was observed. Further interviews confirmed that the resident had only received 400 cc since the previous afternoon, and staff acknowledged that the resident was not receiving the total amount of tube feeding as ordered. Facility policy required adequate nutritional support through enteral nutrition as ordered, but this was not followed in this instance.