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F0684
D

Failure to Follow Physician's Orders and Labeling Requirements for Tube Feeding

Baltimore, Maryland Survey Completed on 07-23-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency was identified when a resident receiving tube feeding was observed to have their feeding running at 75 mL/hour during the morning, despite an active physician's order specifying that the tube feeding should be administered from 5 PM to 3 AM only. Additionally, the flush bag associated with the tube feeding was not labeled as required. The resident's electronic medical record confirmed the specific timing and rate for the tube feeding, and facility policy required both the tube feeding and flush bag to be properly labeled with the resident's information, formula details, rate, date and time hung, and nurse initials. These requirements were not followed, as observed by the surveyor and confirmed in interviews with facility staff.

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