Failure to Administer Enteral Feeding as Ordered
Penalty
Summary
The facility failed to maintain acceptable parameters of nutritional status for a resident with a feeding tube by not administering enteral feeding as ordered by the physician. The resident, a male with dysphagia and gastrostomy status, had a physician order for enteral feeding to be administered for at least 20 hours daily. Record review showed that the enteral feeding was removed at 11:00 AM each day, but there was no documentation of when it was restarted. On the day in question, observations confirmed that the resident's feeding pump was off from 11:10 AM through 4:20 PM, exceeding the allowed 4-hour downtime specified for care activities. Nursing staff interviews revealed that the feeding was not restarted as required, and the lapse was not communicated during shift change. The responsible nurses acknowledged that the resident was at risk for not receiving adequate nutrition due to the failure to follow the physician's orders. The facility's policy required that tube feedings be administered according to physician orders to meet nutritional requirements. The Director of Nursing and the Administrator both confirmed that the nurses were responsible for ensuring the feeding was not off for a prolonged period and that failure to do so could result in the resident not receiving necessary nutrition. The deficiency was identified through interviews, record reviews, and direct observation, all indicating that the resident's enteral feeding was not managed in accordance with the prescribed orders.