Failure to Administer Prescribed Enteral Feeding Formula
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia, aphasia, and gastrostomy status, who was dependent on staff for activities of daily living and received the majority of their nutrition and hydration via tube feeding, was not provided the prescribed enteral feeding formula. The physician's order specified continuous administration of Isosource 1.5 at 55 ml per hour, but instead, Vital 1.5 formula was administered. This substitution was observed during a survey, and the medication administration record indicated the feeding was signed as administered according to the order, despite the actual formula being different. Interviews with nursing and dietary staff confirmed that no physician order or dietitian consultation had been made to authorize the substitution of the enteral formula. The supply room was found to have the prescribed Isosource 1.5 formula available at the time of the incident, and the medical records coordinator was unable to explain why the incorrect formula was used. Facility policy required that enteral nutrition be administered as prescribed, in accordance with professional standards, which was not followed in this instance.