Delay in Initiation of Ordered Tube Feeding Due to Supply and Communication Failures
Penalty
Summary
A deficiency occurred when a resident admitted with protein-calorie malnutrition and dysphagia, and with a J-tube for enteral feeding, did not receive tube feeding as ordered by the physician. Upon admission, the resident had physician orders for Vital AF 1.2 at 55 ml per hour for 22 hours daily via J-tube, with hourly water flushes. Nursing staff documented that the prescribed tube feeding formula and necessary administration supplies were not available upon the resident's arrival, resulting in a delay in initiating the tube feeding. Although the resident arrived with some containers of the formula, staff were unable to locate the appropriate supplies and did not start the feeding as ordered. The resident went approximately 11 and a half hours without the ordered tube feeding, missing about 660 ml of nutrition. During this period, staff were able to administer medications and flush the J-tube as ordered, but the enteral nutrition was not provided. Interviews revealed that the on-call APRN or physician was not contacted to establish an alternate plan when the feeding could not be started, despite facility policy requiring appropriate treatment for residents with feeding tubes. The feeding and supplies were later found to have been present in the facility, but not located or used by the nursing staff at the time of need.