Failure to Administer Enteral Feeding at Physician-Ordered Rate
Penalty
Summary
A deficiency was identified when a resident with multiple complex medical diagnoses, including pneumonitis due to inhalation, COPD with acute exacerbation, heart failure, cerebral infarction, and aphasia, did not receive enteral feedings as ordered by the physician. The resident, who was dependent for all activities of daily living and had a BIMS score of 0, was admitted with a physician's order for Osmolite 1.2 to be administered at 40 ml/hour via pump, with a corresponding care plan intervention. During observation, it was found that the tube feeding was infusing at 50 ml/hour instead of the ordered 40 ml/hour. Interviews with facility staff, including an LPN, the ADON, and the DON, confirmed that the feeding rate should have been 40 ml/hour as per the physician's order, and that the order had been updated during physician rounds. The failure to administer the enteral feeding at the prescribed rate constituted a lack of adherence to professional standards of quality care.