Failure to Ensure Accurate Tube Feeding Documentation and Physician Notification
Penalty
Summary
The facility failed to ensure that all residents with tube feedings received sufficient nutrition due to staff misunderstanding and inconsistent documentation practices. Staff did not consistently document tube feeding intake accurately, failed to record when the amounts administered varied from the physician's orders, and did not notify the physician when such variances occurred. Multiple staff interviews revealed confusion regarding where and how to document tube feeding intake and output in the Medication Administration Record (MAR), with some staff documenting anticipated amounts rather than actual amounts administered, and others mistakenly recording oral intake or water flushes as tube feeding intake. There were also discrepancies in the timing of documentation, with the MAR not aligning with the actual start and end times of tube feedings as ordered by the physician. A resident with a history of nontraumatic intracerebral hemorrhage and dysphagia was identified as being at nutritional risk and dependent on tube feeding for adequate nutrition. The resident's care plan and physician orders specified the required tube feeding regimen, including the amount and timing of feedings. However, review of the MAR showed multiple instances where the documented intake did not match the ordered amount, including days with significantly less or more than the prescribed volume, and days with no intake recorded. Staff interviews confirmed that these discrepancies were not consistently explained in the resident's record, and physician notification was not documented when variances occurred. Further, staff expressed confusion about the documentation process, with some admitting to not being trained on the specific unit or not understanding the MAR system. There was also a lack of clarity regarding when to notify the physician about deviations from the ordered tube feeding amounts, with some staff believing notification was only necessary if the variance persisted over several days. The facility's policies required documentation of changes in condition and physician notification, but these were not followed in practice, leading to a failure to provide appropriate care and monitoring for the resident receiving tube feedings.