Failure to Administer Enteral Feeding at Physician-Ordered Rate
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident receiving enteral nutrition via a feeding tube was administered the correct rate of formula as ordered by the physician. The resident, who had severe protein-calorie malnutrition and required a feeding tube for nutrition, had a physician order for Isosource 1.5 calorie formula to be administered continuously at 53 ml/hr. However, multiple observations revealed that the feeding pump was set at 55 ml/hr instead of the prescribed rate. Nursing staff, including an LVN, acknowledged the discrepancy and stated that charge nurses were responsible for verifying orders each shift and each time the feeding was administered. The resident's care plan included interventions to check tube placement and gastric residuals per protocol, and the facility's policy required that enteral feedings be administered as ordered by the physician. Despite these protocols, the incorrect rate was administered on more than one occasion, and the error was confirmed by both nursing staff and facility leadership during interviews. The DON and Administrator both stated that nurses were expected to follow physician orders and that monitoring was their responsibility, but the error was not identified or corrected in a timely manner.