Failure to Provide Prescribed Enteral Nutrition and Monitor Weight
Penalty
Summary
The facility failed to provide appropriate enteral feeding care for a resident who was dependent on tube feeding due to dysphagia and other medical conditions. The resident was admitted with a low body mass index (BMI) and was noted to be underweight and cachectic. Despite professional standards and facility policy requiring regular weight monitoring, there were no weekly weights recorded after admission, and the resident experienced significant weight loss over a short period. The physician's order for enteral feeding specified a rate of 80 ml/hr for 20 hours daily, but did not clearly state the total daily volume. Observations revealed inconsistencies in the administration of the feeding formula, with the pump being inactive during scheduled feeding times and less formula being administered than prescribed. Over a three-day period, the resident received only 61.2% of the ordered nutrition, with no documentation explaining the missed feedings. Interviews with nursing staff indicated a lack of awareness regarding the total volume to be administered and unfamiliarity with the pump's monitoring features. The failure to administer the prescribed amount of enteral nutrition and to monitor the resident's weight as required led to inadequate nutritional support, as evidenced by ongoing weight loss and insufficient intake documented during the survey.