Failure to Document Tube Feeding and Flush Intake as Care-Planned
Penalty
Summary
The facility failed to implement a person-centered care plan for a resident with multiple complex medical conditions, including dysphagia following cerebral infarction, dementia, protein-calorie malnutrition, and a PEG tube for nutrition. The resident was care-planned to receive Jevity 1.2 cal at 50mL/hr with a 25mL/hr flush, and the care plan required monitoring and documentation of intake and output every shift. Despite these documented interventions, review of the resident's records revealed that intake of tube feeding and flushes was not documented each shift on multiple dates. Interviews with both an LPN and the Director of Nursing confirmed that the intake of tube feeding and flushes had not been documented as required by the care plan. The lack of documentation was observed on several specific dates, indicating a failure to follow the established care plan for monitoring and recording the resident's nutritional and fluid intake as ordered by the physician and outlined in the care plan.