Failure to Document Enteral Feeding and Monitor Weights for Tube-Fed Resident
Penalty
Summary
The facility failed to provide necessary care and services related to enteral feeding for one resident with a gastrostomy tube. Specifically, the facility did not document the total amount of enteral formula administered during the day shift as ordered by the physician. The resident was prescribed a specific enteral feeding regimen, including Jevity 1.2 cal at a set rate and volume, with instructions to record the total amount infused each day. However, review of the Medication Administration Record (MAR) for March and April did not show any documentation of the total enteral formula administered, as required by the physician's order. Additionally, the facility did not perform weekly weight monitoring for the resident as recommended by the dietician and outlined in facility policy. The resident, who was admitted with diagnoses including traumatic brain injury, acute respiratory failure, dysphagia, and gastrostomy status, experienced a significant weight loss of 11.1% over a one-month period. The weight record showed that weekly weights were not obtained for four weeks as required for residents at high nutritional risk, and this was confirmed by the dietician during an interview.