Failure to Resume Tube Feeding as Ordered After Care
Penalty
Summary
A resident with multiple diagnoses, including gastrostomy, dysphagia, vascular dementia, and severe cognitive impairment (BIMS score of 03), was observed in bed with a feeding pump at the bedside that was turned off. The feeding pump was connected to the resident and contained a bottle of Jevity 1.2. Upon inquiry, a registered nurse confirmed that the pump was off and stated that the tube feeding is supposed to run continuously for 24 hours, with flushes every 4 hours. The nurse indicated that the certified nurse assistant may have turned off the pump during patient care and did not notify the nurse to resume the feeding afterward. The facility's care plan required the resident to receive tube feeding as ordered, with the head of the bed elevated, and for the nurse to be responsible for turning the feeding pump on and off during care or therapy. The Director of Nursing confirmed that if the feeding pump is off when it should be infusing, the resident would not receive the scheduled feeding. The failure to ensure the feeding pump was turned back on after care resulted in the resident not receiving tube feeding in accordance with the physician's order.