Failure to Provide Enteral Nutrition According to Physician and Dietitian Orders
Penalty
Summary
A resident with a diagnosis of gastrostomy was readmitted to the facility and required enteral nutrition via a feeding tube. The care plan indicated the need for a feeding tube, and a physician's order initially directed staff to administer Nutren 2.0 at 55 ml per hour for 18 hours. Subsequent physician's orders changed the formula to Jevity 1.5 for 20 hours but did not specify the administration rate. The dietitian recommended a rate of 66 ml per hour of Jevity 1.5 to meet the resident's nutritional needs. Observation revealed that the tube feed pump was set to deliver Jevity 1.5 at 50 ml per hour, and staff were unable to identify a rate in the physician's order. Interviews with the LPN and DON confirmed that the order for Jevity 1.5 lacked a specified rate, and the 50 ml per hour rate was initiated in error. There was no evidence that the recommended rate of 66 ml per hour was ever administered, and the DON confirmed that the order was transcribed incorrectly, omitting the required rate.