Failure to Administer Tube Feedings as Ordered for Resident with Diabetes and Dysphagia
Penalty
Summary
A deficiency occurred when nursing staff failed to administer enteral tube feedings as ordered by the physician for a resident with a history of diabetes mellitus type 2, anxiety, major depressive disorder, and dysphagia requiring a gastrostomy tube. The resident had specific physician orders for continuous tube feeding during nighttime hours and for regular blood glucose monitoring and insulin administration. Despite these orders, nursing staff on multiple occasions turned off the resident's tube feeding early in response to elevated blood glucose levels, without obtaining a physician's order or notifying the provider as required. Documentation of these actions was not consistently entered into the medical record or medication administration record (MAR). Interviews with staff revealed that at least two nurses had independently decided to stop the tube feeding early due to concerns about high blood sugar, believing it was appropriate nursing judgment. One nurse reported being told by another nurse to turn off the feeding, and both indicated a lack of clear guidance or understanding that tube feedings should not be stopped without a provider's order. The unit manager and nurse practitioner confirmed that tube feedings were being stopped early by night shift nurses, and that this practice was not in accordance with the resident's care plan or physician orders. The registered dietician and medical director both stated that stopping tube feedings early could result in the resident not receiving their minimal nutritional needs, potentially contributing to weight loss. The resident's guardian raised concerns about the tube feeding not running for the full prescribed duration and noted observed weight loss. The issue was brought to the attention of facility leadership, including the DON and nurse practitioner, who confirmed that staff had not consistently followed the physician's orders for tube feeding administration. The DON acknowledged that she was not aware of the full extent of the issue and had only addressed it with one nurse, despite evidence that multiple staff were involved.