Failure to Document Tube Feeding Residual Amounts
Penalty
Summary
Facility staff failed to document the amount of gastric residuals when checking a resident's tube feeding residuals, as required by physician orders and facility policy. The resident in question had an order to check gastric residual volume prior to feeding, with instructions to hold feeding and notify the physician if the residual exceeded a specified amount. The care plan and medication administration record (MAR) both indicated that gastric residuals were to be checked three times daily, and the MAR showed that these checks were consistently performed. However, the actual amounts of gastric residuals were not documented in the resident's clinical record, despite facility policy requiring this information to be recorded. This omission was confirmed by the Director of Nursing. The resident involved had moderate cognitive impairment and was receiving enteral nutrition due to an inability to eat or drink, making accurate documentation of tube feeding residuals critical for their care.