Failure to Assess and Authorize Self-Administration of Enteral Nutrition
Penalty
Summary
The facility failed to ensure that an assessment for self-administration of enteral nutrition was completed for a resident who was observed independently administering his enteral nutrition via gastrostomy tube. During observation, the resident was seen self-administering his enteral nutrition with the head of his bed flat. The resident confirmed that although nurses typically provide his enteral nutrition during scheduled meal times, he also self-administers it. Review of the resident's medical record revealed diagnoses including malignant neoplasm of the thyroid gland, severe protein calorie malnutrition, gastroesophageal reflux disease, and gastrostomy status. The resident had a BIMS score indicating intact cognition and had active physician orders for enteral feeding, but there was no documentation of an assessment for self-administration of enteral nutrition. Further review showed there was no physician order authorizing the resident to self-administer his enteral nutrition, nor was there any indication in the care plan that self-administration was permitted or planned. Facility policy requires an interdisciplinary team assessment and physician order before a resident may self-administer medications, including enteral nutrition, and mandates that the care plan reflect this arrangement. Staff confirmed that no such assessment, order, or care plan focus was present for this resident.