Failure to Provide Prescribed Enteral Feeding to Resident
Penalty
Summary
A deficiency occurred when a resident who was dependent on enteral feeding did not receive the prescribed diet as ordered by the attending physician. The resident, admitted with diagnoses including type 2 diabetes mellitus, hypertension, gastrostomy, and chronic kidney disease, had a physician's order for Glucerna 1.5 to be administered via gastrostomy tube at a rate of 55 ml per hour for 20 hours daily, totaling 1,100 ml and 1,650 kcal per 24 hours. The order specified the feeding should be on at 2 p.m. and off at 10 a.m., or until the dose was completed, with allowances to hold feedings during ADL care, showers, and transfers. Upon review of the Medication Administration Record (MAR) and Medication Admin Audit Report, it was found that the feeding was not initiated as ordered. The MAR indicated the feeding was signed off as 'off' at 10 a.m., but there was no documentation that the feeding had been started prior to this time. The Assistant Director of Nursing (ADON) confirmed that the feeding should have been set up immediately upon admission, as the facility had the necessary supplies and equipment available. The ADON also noted that the nurse did not sign that the feeding was started, resulting in the resident missing 14 hours of prescribed feeding. As a result of this omission, the resident did not receive 770 ml of the prescribed enteral nutrition. The facility's policy and procedure for enteral feeding, last reviewed in April 2025, required that enteral feedings be administered via pump as ordered by the physician. The failure to initiate the prescribed feeding regimen led to the resident not receiving the required nutrition and hydration as ordered.