Failure to Follow Physician Orders for Tube Feedings
Penalty
Summary
A resident with diagnoses including cerebral infarction, acute respiratory failure with hypoxia, dysphasia, and bilateral paralysis was admitted to the facility and required nutritional tube feedings as ordered by a physician. The physician's order specified Nutren 2.0 complete liquid nutrition, to be administered as a 250 mL bolus five times daily. However, on one day, the resident did not receive the scheduled enteral feedings at 8:00 A.M., 11:00 A.M., and 12:00 P.M., only receiving feedings later in the day at 5:00 P.M. and 9:00 P.M. The resident, who had no cognitive deficits and was aware of her feeding regimen, reported missing two feedings and expressed frustration at not being informed about the reason for the missed feedings. The Director of Nursing confirmed that the missed feedings were due to a problem with the resident's tube feeding pump. Review of facility policy indicated a general commitment to providing nutritional care but did not include a specific policy on following physician's orders. The deficiency was identified through medical record review, resident and staff interviews, and policy review, and it was determined that the facility failed to ensure physician orders for tube feedings were followed for this resident.