Failure to Follow Physician Orders for Feeding Tube Administration
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
A deficiency occurred when a resident with a feeding tube did not receive care in accordance with physician orders. The resident had a physician order for enteral feeding with Jevity 1.5 at a rate of 66 ml/hr for 18 hours daily, administered via pump. However, staff left the feeding tube running at a rate of approximately 300 ml/hr, significantly exceeding the prescribed rate. This error was discovered when staff observed feeding formula bubbling out of the resident's tracheostomy site. Multiple staff interviews confirmed that the feeding tube was set incorrectly and that the physician's orders were not followed.