Failure to Administer Tube Feeding as Ordered and Implement Dietitian Recommendations
Penalty
Summary
Licensed nursing staff failed to administer gastrostomy tube (GT) feeding to a resident as ordered by the physician and as outlined in the facility's policy and procedure for enteral nutrition. The resident, who had diagnoses including Parkinson’s disease and dysphagia, was dependent on staff for all activities of daily living and required continuous GT feeding at a specific rate. Observations revealed that the feeding was administered at 65 ml/hr instead of the ordered 60 ml/hr. Both the LVN and DON confirmed that the physician’s order was not followed, and the RD noted that the resident had experienced significant weight gain over the past six months, with the feeding rate being a contributing factor. In a separate incident, the facility did not implement or communicate the registered dietitian’s (RD) recommendation for another resident to start multivitamins and minerals. The resident, who had severe cognitive impairment and was dependent on staff for daily care, had a nutrition screening indicating the need for multivitamins. However, this recommendation was not included in the dietary recommendations form, nor was it communicated to the resident’s physician. Interviews with nursing staff and the DON confirmed that the RD’s recommendation was not followed up, and there was no documentation that the physician had been notified. The facility’s policies and procedures required that enteral nutrition be provided as ordered by the physician and that all dietary recommendations from the RD be reviewed by the physician and documented by nursing staff. In both cases, the required processes were not followed, resulting in deficiencies related to the administration of nutrition and communication of dietary recommendations.