Failure to Follow Tube Feeding Orders and Formula Administration
Penalty
Summary
A deficiency occurred when a resident with a history of GERD and choledochoduodenal fistula, who required tube feeding, did not receive care and services as ordered. The resident's physician orders specified administration of free water via feeding tube at 35 ml/hr for 18 hours per day and enteral feeding with Peptamen AF for the same duration. However, staff administered water flushes at 100 ml/hr instead of the ordered rate, and the resident subsequently experienced a large emesis. The provider was notified, tube feeding was held, and the resident was sent to the emergency department due to ongoing vomiting and concerns about altered electrolytes from the excess water. Additionally, staff ran out of the prescribed Peptamen AF formula and administered Peptamen 1.5 without a physician order or approval from the registered dietician or the initiating team. The resident reported increased digestive symptoms after receiving the incorrect formula. Staff interviews confirmed the errors in both the water flush rate and the tube feeding formula administration.