Failure to Administer Prescribed GT Feeding and Water Flush Rates
Penalty
Summary
The facility failed to provide appropriate care and services related to gastrostomy tube (GT) management for two residents. For one resident, the prescribed enteral feeding rate of Glucerna 1.2 was 50 ml/hour, as ordered by the physician and documented in the care plan and nutritional assessment. However, observations revealed that the resident was receiving the feeding at a rate of 65 ml/hour, which was 15 ml/hour higher than the physician's order. This discrepancy was confirmed by both the nursing staff and a review of the medical records. For another resident, the physician's order specified a GT water flush of 35 ml/hour for 20 hours daily, totaling 700 ml/day. Despite this, the resident was observed receiving a water flush at a rate of 30 ml/hour, which was 5 ml/hour less than ordered. Nursing staff verified the order and acknowledged the lower rate being administered. Both residents were documented as lacking capacity to make medical decisions, and the deviations from prescribed care were confirmed through observation, staff interviews, and medical record review.