Failure to Follow Nutrition Support Orders for Tube-Fed Residents
Penalty
Summary
The facility failed to properly transcribe and implement hospital nutrition support orders for one resident who was readmitted, and did not follow physician orders for three residents requiring nutrition support. For the readmitted resident, hospital discharge records specified a continuous tube feeding regimen and nutritional supplements, but the facility delayed starting the supplements and did not initiate the continuous feeding as ordered. This resident, who was severely underweight and had multiple pressure ulcers, experienced a significant weight loss over a short period. For two other residents, observations revealed that tube feedings were not running during times when physician orders indicated they should be. Staff interviews confirmed that tube feedings were sometimes stopped for ADL care or medication administration and not always restarted promptly. One resident experienced a severe weight loss over six months, and the dietitian recommended increasing tube feeding to promote weight stability, but the feeding schedule was not consistently followed as ordered. Facility policy required that physician orders be followed as written and that continuous tube feedings be administered according to the specified schedule or as assessed by the dietitian. However, staff practices, including stopping feedings for care or medication and not resuming them as required, led to residents not receiving adequate nutrition support as ordered. These failures were confirmed through observation, record review, and staff interviews.