Failure to Follow Enteral Feeding Orders and Protocols
Penalty
Summary
The facility failed to follow physician orders and facility policy regarding the care and management of enteral feedings for two residents. For one resident, the head of the bed was observed to be elevated to only 30 degrees on multiple occasions while enteral feeding was infusing, despite a physician's order requiring a 45-degree elevation at all times except during care. Additionally, the same resident's enteral feeding administration set was not changed every 24 hours as ordered; it was observed to be in use beyond the prescribed time frame, with significant feeding already infused through the set. In another instance, a CNA placed a resident's enteral feeding on hold and restarted it during incontinence care, which was outside the CNA's scope of practice according to facility policy and confirmed by the DON and Administrator. The facility's policy specifies that only trained and qualified LPNs and RNs are permitted to prepare, store, administer, or adjust enteral feedings. These actions and inactions resulted in the facility not ensuring that enteral feedings were managed according to physician orders and facility protocols.