Failure to Administer Tube Feeding as Ordered
Penalty
Summary
Staff failed to administer enteral nutrition and hydration according to current physician orders for a resident who was dependent on tube feeding as their sole source of nutrition and hydration. The facility's policy required verification of physician orders and checking the enteral nutrition label against the order before administration, including details such as rate and method. The resident had diagnoses including moderate protein-calorie malnutrition, dementia, dysphagia, gastrostomy status, and iron deficiency anemia, and was assessed as severely cognitively impaired and totally dependent for activities of daily living. Observations on multiple occasions revealed that the resident's feeding tube was connected to the pump, but the pump was not delivering nutrition as ordered. On two separate days, the resident was observed with the tube feeding attached but not running. Interviews with the DON confirmed that the tube feeding was not being administered and that the nurse on the floor was responsible for monitoring the tube feeding.