Failure to Follow Tube Feeding Orders for Resident with Severe Dysphagia
Penalty
Summary
Staff failed to follow the registered dietician's (RD) nutrition orders for a resident with spastic quadriplegia cerebral palsy who was receiving nutrition via both a gastrostomy and jejunostomy tube due to severe dysphagia and cognitive impairment. The RD's order specified that the resident should receive Osmolyte 1.5 continuously at 32ml/hour via the jejunostomy tube, with a one-hour stop time for residual checks. However, observations revealed that the tube feeding pump was turned off and disconnected from 10:00 AM to 2:00 PM daily, contrary to the RD's continuous feeding order. Staff interviews confirmed this practice, with an LPN stating the feeding was held for four hours each day, and the VP for Nutrition and DON both acknowledging that the only current order was for continuous feeding with a one-hour hold for residual checks. Record review showed that previous orders for intermittent feeding had been discontinued, and the current order was for continuous feeding to address the resident's history of vomiting. Despite this, staff continued to implement a prolonged feeding hold not supported by the current physician or RD orders. This deviation from prescribed nutrition orders placed the resident at risk for health complications and weight loss.