Failure to Administer Enteral Tube Feeding as Ordered
Penalty
Summary
A deficiency occurred when a resident with a history of cerebral vascular accident, dysphagia, and a gastrostomy tube did not receive enteral tube feeding as ordered by the physician. The resident was admitted with orders for nocturnal tube feeding to be infused at 55 ml per hour for 10 hours each night. On the night in question, the resident experienced gastrostomy tube leakage and was sent to the hospital, where the tube was unclogged and flushed. The hospital found no further issues and the resident was returned to the facility with no new orders. Upon return to the facility, nursing staff did not resume the prescribed continuous tube feeding. The assigned nurse for the day shift found that the tube feeding was not infusing and that an old bag of nutritional supplement from two nights prior was still hanging at the bedside. The night shift nurse admitted to not administering the continuous feeding as ordered, instead providing a single bolus of the supplement, despite there being no physician order for this change in administration. There was also no documentation in the medical record of the bolus feeding being given. Interviews with the Registered Dietitian, Nurse Practitioner, and Physician confirmed that the resident should have received the continuous infusion as ordered and that no order existed to substitute a bolus feeding. The Director of Nursing also confirmed that the prescribed method of administration was not followed. The resident, who was severely cognitively impaired and unable to voice her needs, indicated through nonverbal communication that she had not received her feeding and was hungry.