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F0693
D

Failure to Follow Physician Orders for Tube Feeding

Boise, Idaho Survey Completed on 09-12-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to follow physician orders for a resident who required tube feeding due to multiple cancer diagnoses, including cancer of the mouth and esophagus. The resident's care plan specified tube feeding as ordered, with a physician order directing the administration of Jevity 1.5 nutritional supplement at a specific rate and volume. However, during observation, the resident was found to be receiving Glucerna 1.5 instead of the prescribed Jevity 1.5 via PEG tube. This was confirmed by both the unit manager and an LPN, who acknowledged that the incorrect nutritional supplement was being administered and that the physician's order had not been followed. The facility's policy required staff to confirm the physician's order prior to administration, but this was not done in this instance.

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