Failure to Administer Ordered Enteral Feedings
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including cerebral palsy, aphasia, mild protein calorie malnutrition, gastrostomy status, dysphagia, type 2 diabetes mellitus, and bipolar disorder, did not receive enteral feedings as ordered by the physician. The resident's care plan specified the need for a PEG tube for adequate nutritional intake and required tube feedings to be administered according to physician orders. The physician's orders included continuous Glucerna 1.5 feedings via pump overnight, scheduled bolus feedings, and water flushes. On the morning of the survey, observation revealed that the resident's feeding tube was not connected, and the feeding pump was turned off, despite the presence of a full bag of Glucerna and water hanging on the pole. Interviews with nursing staff confirmed that the overnight continuous feeding had not been administered as ordered, and there was no documentation or report of the resident refusing the feeding. The DON confirmed that the resident should have received the ordered continuous feeding but did not.