Failure to Enter and Implement Tube Feeding and Free Water Orders After Hospital Readmission
Penalty
Summary
The facility failed to enter and implement hospital discharge orders for tube feedings and free water administration for a resident who was readmitted after hospitalization with a feeding tube. Upon return, the resident's previous tube feeding and free water flush orders were not entered into the medication administration record (MAR), despite staff administering tube feedings and water flushes based on prior routines and verbal reports. Multiple nurses reported continuing tube feedings and water flushes as before, without verifying that appropriate orders were present in the MAR. The Unit Manager acknowledged receiving the hospital discharge orders but did not enter the tube feeding formula, rate, or free water flushes into the electronic documentation system. The Registered Dietician was not contacted for clarification of dietary orders after the resident's return. Nursing staff administered tube feedings and water flushes without documented orders, relying on previous practices and nursing judgment rather than current, physician-authorized instructions. The physician confirmed that nursing staff should not use their own judgment for tube feeding water flushes and that the facility should have contacted him to clarify and obtain proper orders. The Director of Nursing stated that the hospital discharge orders were not reviewed during the morning meeting following the resident's readmission, and the Administrator expected all discharge orders to be clarified and entered into the system, which did not occur in this case.