Failure to Follow Physician's Order for Feeding Tube Water Flush
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A deficiency occurred when staff failed to implement a physician's order for a resident with a history of stroke, dysphagia, and a feeding tube. The physician's order specified that the resident's feeding tube should be flushed with 200 ml of water every six hours, totaling 800 ml daily. However, observation revealed that the water flush was being administered via a pump set at 30 ml per hour for 22 hours, resulting in only 660 ml of water being delivered per day, which is 140 ml less than ordered. Interviews with an LPN and the Director of Nursing confirmed that the pump was not programmed to deliver the total amount of water as prescribed by the physician.