Failure to Notify Provider of Inability to Administer Ordered Tube Feeding
Penalty
Summary
The facility failed to ensure timely notification of the medical provider when a resident was unable to receive ordered tube feeding upon admission. The resident, admitted with diagnoses including protein-calorie malnutrition and dysphagia, had orders for J-tube feeding with a specific formula and rate. Upon admission, nursing staff were unable to locate the required tube feeding formula and administration supplies, resulting in the resident not receiving the prescribed feeding for approximately 11 and a half hours. Documentation shows that the formula and supplies were present in the facility but not found or used by the staff on duty. Nursing staff did not notify the APRN or physician about the inability to provide the ordered feeding, as confirmed by interviews and review of the medical record. Both the evening and night shift nurses acknowledged awareness of the issue but did not contact the medical provider or document any notification. Facility policy required immediate consultation with the physician when treatment could not be provided as ordered, but this was not followed. The deficiency was identified through clinical record review, staff interviews, and policy review.