Failure to Administer Enteral Water Flushes per Physician Orders
Penalty
Summary
A deficiency occurred when the facility failed to ensure that water flushes for a resident with a gastrostomy tube were administered according to the most current physician orders. Observations and interviews revealed that the resident's feeding pump was set to deliver water flushes at 160 ml every 6 hours, despite a documented recommendation and approved order to decrease water flushes to 100 ml every 8 hours. The discrepancy was noted during multiple observations, and staff confirmed the settings on the pump did not match the updated orders. The Director of Nursing and Registered Nurse both referenced the need to follow physician orders for enteral feedings and flushes, but the actual practice did not align with the documented changes. The resident involved had significant medical complexities, including end stage renal disease requiring dialysis, chronic heart failure, and severe cognitive impairment. The dietician had recommended the reduction in water flushes due to concerns about fluid overload and the resident's ability to tolerate excess fluids, given their dialysis and cardiac status. Despite these recommendations and the nurse practitioner's approval, the water flushes continued at the previous, higher rate, contrary to the updated physician order.