Failure to Accurately Transcribe and Administer Enteral Feeding Orders
Penalty
Summary
A resident with diagnoses including dysphagia and gastrostomy status was admitted to the facility and had physician orders for enteral feeding of Glucerna 1.2 at 40ml/hr for 16 hours. However, the transcribed admission enteral orders incorrectly specified Glucerna at 45ml/hr for 16 hours or until a total volume of 720ml. On review, it was found that the resident received a total volume of 1191ml, significantly exceeding the ordered amount. The resident was found with a hard and distended abdomen, and a residual of 1000cc was pulled from the stomach. The nurse stopped the feeding and notified the on-call NP, who ordered the feeding to be held and a STAT abdominal x-ray. Interviews with the DON and nursing staff confirmed awareness of the error, with staff indicating that the enteral pump would continue running unless a stop time was set. Facility policy required that feeding tubes be used and maintained according to physician orders and current clinical standards, including ensuring administration of enteral nutrition is consistent with practitioner orders. The failure to accurately transcribe and administer the enteral feeding order resulted in the resident being overfed.