Failure to Monitor and Document Tube Feeding Residuals
Penalty
Summary
Staff failed to monitor and document tube feeding residuals for a resident with a feeding tube, despite a physician's order requiring residuals to be checked before each feeding. The order specified that if the residual was above 60 milliliters, feeding should be held for one hour and rechecked, and if still elevated, the physician should be notified. The resident's care plan also included interventions for administering enteral feedings as ordered, checking tube placement, flushing the tube, and notifying the physician for increased residuals. Medical record review showed no documentation of tube feeding residuals being checked for the resident during the specified period. This was confirmed by the Assistant Director of Nursing, who acknowledged the absence of documentation despite the existing physician's order. Facility policy required staff to measure and record gastric residual volume to assess feeding tolerance and minimize aspiration risk, but this was not followed for the resident in question.