Failure to Implement Physician-Ordered Enteral Feeding Care Plan
Penalty
Summary
A deficiency occurred when a resident with a history of acute kidney failure, dysphagia, and a feeding tube was observed receiving Glucerna 1.2 calorie formula instead of the physician-ordered Jevity 1.5 calorie formula. The care plan and physician orders specified Jevity 1.5 at 50 ml/hr for 20 hours, with water flushes as ordered, due to the resident's compromised kidney function. Despite these orders, staff administered Glucerna, which was not recommended by the Registered Dietitian because of the resident's abnormal kidney labs. The error was discovered during a survey observation, with photographic evidence confirming the incorrect formula in use. Interviews with staff revealed that the LPN on duty did not verify the feeding formula during morning rounds, and the previous shift had hung the Glucerna. The DON stated that department heads and floor nurses are responsible for checking enteral feedings daily, but this protocol was not followed. The RN Unit Manager also acknowledged seeing the feeding in progress but did not confirm it matched the physician's order. The facility's policy requires comprehensive, person-centered care plans with measurable objectives to be implemented, but this was not adhered to in this instance.