Failure to Administer Enteral Feedings as Ordered for Tube-Fed Resident
Penalty
Summary
A diabetic resident with severe dysphagia, recurrent pneumonia, and a newly placed gastrostomy tube was admitted to the facility following hospitalization for multiple acute conditions. Upon admission, medical orders were entered for enteral feedings via PEG tube at specific intervals, with corresponding water flushes before and after each feeding. However, documentation on the Medication Administration Record (MAR) showed that none of the scheduled enteral feedings were administered on the day of admission, and there was no indication that the resident received any nutrition as ordered. Interviews with staff revealed significant communication and documentation failures. The interim DON, who was the Unit Manager at the time, stated that orders were entered and that a nurse was assigned responsibility for the resident. However, the assigned nurse reported he was not informed about the resident's admission or his responsibility for the resident, and only became aware of the situation when called to address bleeding at the gastrostomy tube site. He was unable to locate the resident's orders or discharge summary in the electronic record and did not administer the enteral feeding. The nurse on the following shift also could not access the necessary orders or discharge summary and did not provide the enteral feeding, though she did perform tube flushes as prompted by the MAR. On the day after admission, a new order for enteral feeding was entered with revised administration times. The MAR indicated that only two feedings were documented as given that day, rather than the four scheduled. The medication aide confirmed that she only called the covering nurse to administer the enteral feeding twice, as those were the only times flagged on the MAR. There was no documentation of hypoglycemic episodes during this period, but the resident did not receive enteral feedings as ordered for two consecutive days.