Failure to Provide Ordered Tube Feeding Due to Unresolved Pump Clog
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, dysphagia following cerebral infarction, hemiplegia, hemiparesis, and aphasia did not receive the ordered amount of tube feeding. The resident was dependent for all activities of daily living and had a physician order for continuous enteral nutrition at 75 cc per hour, with specific instructions for formula type and flushes. Observations revealed that the resident's tube feeding pump was repeatedly beeping and displaying a 'clog in line downstream' error, with 370 ml remaining in a 1000 ml container that had been initiated earlier that day. The tube feeding was not infusing as ordered. Further review and interviews confirmed that the tube feeding should have been completed by early afternoon, but the resident had not received the full prescribed amount. The LPN on duty at the time had not yet checked on the resident and was unaware that the tube feeding had not been infusing. This resulted in the resident not receiving the ordered nutrition, as confirmed by both observation and staff interview.