Failure to Administer Correct Enteral Tube Feeding Rate
Penalty
Summary
The facility failed to provide the correct enteral tube feeding rate for one resident who had a gastrostomy and was dependent on tube feeding due to multiple diagnoses, including encephalopathy, dysphagia, seizures, aspiration pneumonia, and dementia. The resident was ordered by the physician to receive enteral tube feeding at a rate of 65 mL per hour. However, during observation, the tube feeding machine was found to be set at 45 mL per hour, contrary to the physician's order and the label on the feeding tube. Staff initially stated the label was incorrect, but upon review of the order, it was confirmed that the machine should have been set to 65 mL per hour. The resident's medical records indicated a history of gradual weight loss and a recent five-pound loss, with the dietician noting the need for increased calories and protein from tube feeding. The facility's policy required staff to check the enteral nutrition label against the physician's order before administration, including verifying the rate of administration. Despite this policy, the error in the feeding rate was not identified until observed by surveyors, and both the RN and DON acknowledged that the incorrect rate could place the resident at risk for malnutrition and skin breakdown.