Failure to Clarify Conflicting Enteral Feeding Order
Penalty
Summary
The facility failed to follow professional standards of practice by not clarifying a physician's order for enteral feeding for one resident. The resident, who had severe cognitive impairment and was admitted with diagnoses including pneumonia, dysphagia, gastrostomy, and malignant neoplasm of the major salivary gland, had a physician's order in the electronic medical record that contained conflicting instructions regarding the number of cans of Jevity 1.2 to be administered per day. The order stated both eight and six cans in the same instruction, creating ambiguity in the resident's care plan. Despite this discrepancy, the error was not corrected by the nursing staff or clarified with the physician. Interviews with the registered dietitian and regional registered dietitian confirmed the presence of the conflicting order and the lack of correction. The facility's policy required staff to verify medication and feeding orders before administration, but this was not followed in this instance. The deficiency was identified through observation, interview, and record review, and facility leadership could not provide an explanation for the failure to clarify the order.