Failure to Accurately Document and Administer Ordered Enteral Nutrition
Penalty
Summary
The facility failed to ensure that enteral nutrition was administered in accordance with physician orders and professional standards for a resident receiving tube feeding. Specifically, the staff did not accurately document or reconcile the amount of enteral formula and fluids administered with the amounts ordered by the physician. The facility's policy required that tube feedings be administered per physician orders and that staff evaluate the amount of feeding to ensure the resident received the correct nutrition and hydration. However, review of the resident's health records showed discrepancies between the ordered and administered amounts, and staff did not total or verify the amounts delivered as required. Observation and interviews revealed that a registered nurse stopped the tube feeding pump without verifying or documenting the total amount of formula and water administered, and the feeding bottle lacked a start date or time. The nurse admitted to not calculating the total administered and relied solely on the order for guidance. The Director of Nursing confirmed that staff were expected to total and document the amounts each shift, but this was not done. The resident involved was dependent on tube feeding for more than half of their daily caloric intake and required specific amounts of formula and water as ordered by the physician.