Failure to Provide Continuous Enteral Feeding as Ordered
Penalty
Summary
A deficiency occurred when a resident who was dependent on enteral nutrition via a G-tube did not receive prescribed feedings for approximately 11 hours. The resident, who had diagnoses including dementia, dysphagia, Parkinson's disease, and seizure disorder, was ordered to receive Isosource 1.5 at 70cc/hr for 22 hours daily. On the day of the incident, the resident's feeding tube was disconnected by an LVN around 11:30 AM after the resident experienced a fall. The feeding tube was not reconnected until approximately 10:54 PM that night. During this period, the resident was observed to be without his feeding pump, and the pump itself was left in the room turned off. The lapse in care was discovered when the resident's family member, who had a camera in the room, noticed the disconnection and notified facility staff. Documentation and interviews confirmed that the nurse responsible forgot to reconnect the feeding tube after assisting the resident post-fall. The physician and DON were notified after the incident was brought to their attention. The resident did not experience any immediate adverse effects, as confirmed by assessments, lab results, and weight checks. However, the failure to follow physician orders and provide continuous enteral feeding as prescribed constituted a deficiency in care for residents receiving nutrition by enteral means.