Failure to Administer Ordered Enteral Nutrition Volumes
Penalty
Summary
The facility failed to ensure that residents receiving enteral (tube) feeding received the amount of nutrition ordered by their physicians. For five of eight residents reviewed, the recorded daily total volume of tube feeding administered did not match the physician's orders on multiple occasions. For example, one resident with an order for Glucerna 1.5 at 63 mL/hour for 20 hours (totaling 1260 mL per day) received amounts ranging from 316 mL to 2382 mL, with discrepancies noted on numerous days in both July and August. There was no documentation in the clinical records addressing these discrepancies. Another resident with a history of stroke, dysphagia, and tracheostomy dependence had an order for Osmolite 1.5 at 60 mL/hour for 20 hours (totaling 1200 mL per day), but failed to receive the prescribed amount on several days in both July and August. The care plan identified a risk for malnutrition, but the clinical record did not provide evidence that the ordered volume was consistently administered. Similar discrepancies were found for other residents, including those with orders for Jevity 1.5 at various rates and volumes, with the actual amounts received often falling short of the prescribed totals. Interviews with licensed staff and the Director of Nursing confirmed that the residents did not receive the ordered amounts of enteral nutrition and that there was a lack of documentation explaining the variances. The facility's failure to provide the prescribed volume of tube feeding and to document reasons for discrepancies was identified through review of physician orders, medication administration records, and staff interviews.