Failure to Provide Ordered Enteral Nutrition Due to Formula Substitution
Penalty
Summary
A review of the medical record and staff interviews revealed that a resident with diagnoses including malignant neoplasm of the lung, malnutrition, depression, and a history of falls was admitted with orders for nocturnal enteral feeding using Jevity 1.5 at 70 mL/hr via PEG tube. The care plan specified that tube feeding should be administered as ordered due to the resident's inability to consume adequate nutrition orally. The resident was cognitively intact and required varying levels of assistance for activities of daily living, and was coded for a feeding tube on the Minimum Data Set. Despite the physician's order for Jevity 1.5, the facility did not have this formula available upon admission. Instead, an LPN reported that Jevity 1.2 was started two days after admission, and the resident went without the ordered Jevity 1.5 for two nights. This deviation from the physician's order resulted in the resident not receiving the prescribed enteral nutrition as required.