Failure to Follow Physician Orders for Feeding Tube Flushes
Penalty
Summary
A deficiency was identified when a resident with a gastrostomy tube did not receive water flushes according to the physician's orders. The resident, who had diagnoses including muscle weakness, dysphagia, diabetes mellitus, and gastrostomy status, was dependent on tube feeding and water flushes as documented in their care plan. The physician's order specified tube feeding at 65 mL per hour and water flushes at 50 mL per hour. During observations, it was found that the feeding pump was set to deliver 60 mL per hour of water flushes, which was confirmed by two different nurses at separate times. This setting did not match the physician's order for 50 mL per hour. The facility's policy required staff to follow physician orders for feeding tube care, including the frequency and volume of flushes, but this was not adhered to in this instance.