Failure to Administer Tube Feeding as Ordered
Penalty
Summary
A deficiency occurred when a resident who was dependent on tube feeding and water flushes did not receive enteral feedings as ordered by the physician. The resident had diagnoses including acute respiratory failure, hyperlipidemia, hypothyroidism, and insomnia, and was admitted with a care plan indicating the need for tube feeding due to nothing by mouth status. Physician orders specified Glucerna 1.5 at 60ml/hr via pump and water flushes at 250ml every 4 hours. Review of the medication administration record and progress notes for the relevant dates showed no documentation that the tube feeding was held or refused. On observation, the resident's feeding pump was found turned off, and the resident was unaware of how long it had been off. The LPN on duty at the time was also unaware that the pump was off and had not been notified of any issues during shift change. Another LPN from the previous shift reported turning off the tube feeding due to the resident's complaint of stomach pain and turning it back on a few hours later, but could not recall hearing the feeding alarm during the night. The DON was notified of issues with the tube feeding but did not know why or for how long the feeding had been off, despite the resident's orders requiring continuous feeding.