Incorrect Administration of Enteral Nutrition Due to Feeding Pump Setup Error
Penalty
Summary
A deficiency occurred when a resident with a gastrostomy tube (G-tube) was not provided with appropriate treatment and services as prescribed by the physician. The resident, who had diagnoses including Multiple Sclerosis, Dementia, and G-tube status, had specific physician orders for the administration of enteral formula (Jevity 1.5 at 45 ml/hour) and water flushes (200 cc every four hours). Facility policy required staff to be trained and competent in enteral nutrition administration, including verifying the correct rate and volume for tube feedings and flushes. However, the resident's formula and water flushes were placed in the incorrect enteral pump bags, resulting in the resident receiving incorrect volumes of formula and water. The error was identified after a visitor observed the mistake and notified facility staff. Interviews with nursing staff confirmed that the feeding pump tubing, formula, and water flush had been set up incorrectly, leading to the resident not receiving tube feeding and water flushes as ordered. The Assistant Director of Nursing and the Nursing Supervisor both acknowledged that the system had been set up incorrectly, which resulted in the resident not being administered tube feeding and water flushes according to the physician's orders.