Failure to Change Enteral Feeding Set per Physician Order
Penalty
Summary
The facility failed to follow physician orders and facility policy regarding the changing of enteral feeding administration sets for a resident with a feeding tube. Specifically, the order required that the enteral administration set be changed with every bottle of formula, every shift. However, evidence from a family member's screenshot and interview confirmed that the resident's enteral feeding set was not changed for three consecutive days. The Director of Nursing acknowledged that the licensed nurse did not change the enteral feeding bottle and hydration water bag every shift as ordered. The resident involved had a history of dysphagia, a gastrostomy, and adult failure to thrive, and was totally dependent on staff for care, including tube feeding. The resident's care plan identified risks for significant weight loss and dehydration, with interventions requiring staff assistance for tube feeding and water flushes. Facility policy also required formula and administration set changes within specified timeframes. The failure to adhere to these protocols resulted in the resident not receiving the prescribed nutrition and hydration support.