Failure to Ensure Safe Discharge with Required Tube Feeding Equipment
Penalty
Summary
The facility failed to ensure a safe discharge for a resident who required durable medical equipment, specifically a tube feed pump, upon leaving the facility. The resident had diagnoses including dysphagia, moderate protein-calorie malnutrition, and required continuous nutrition via a gastrostomy tube (G-tube) as ordered by the physician. The discharge summary did not include instructions regarding the absence of a tube feed pump or the need for bolus feeding until a pump was available. Documentation showed that the resident was educated on using the tube feed pump and administering medications via G-tube, but there was no evidence that education on bolus feeding was completed prior to discharge. The resident was discharged without the necessary tube feed pump, and the facility had not secured the required feeding supplies or arranged for home health services to provide them at the time of discharge. After discharge, the resident and family reported that the resident was unable to receive nutrition due to the lack of a pump and experienced nausea from bolus feeds. Facility staff continued to search for providers and feeding supplies after the resident had already left, and the resident's insurance eventually sent a month's supply of feeding. Interviews with staff confirmed that the resident was discharged without the pump and that there was a delay in obtaining all necessary equipment and supplies. The facility's policy required a written summary and verbal explanation of the resident's condition at discharge, but the documentation and actions taken did not ensure the resident's needs for continuous tube feeding were met at the time of discharge.