Failure to Administer Tube Feeding per Physician Order Resulting in Aspiration Pneumonia
Summary
A deficiency occurred when a resident with a history of digestive system surgery, aspiration pneumonia, dysphagia, and sepsis did not receive tube feeding in accordance with physician orders and the comprehensive care plan. The resident was admitted with orders for Jevity 1.5 via PEG tube at 60 mL/hr for 20 hours daily, with water flushes every 6 hours. Nursing documentation confirmed the resident was tolerating feedings at the prescribed rate prior to the incident. On the evening of the incident, an LVN hung a new bottle of Jevity but did not verify or adjust the feeding pump's rate, nor did he check the settings during his shift or at shift change. The following nurse also failed to check the pump settings when starting her shift and again when replacing the Jevity bottle during the night. Both nurses acknowledged they did not confirm the pump's rate, and the pump was later found to be running at 200 mL/hr instead of the ordered 60 mL/hr. The facility's policy required verification of provider orders and monitoring of tube feeding settings, but this was not followed. The error was discovered the next morning when a nurse found the resident experiencing nausea and checked the pump, identifying the incorrect rate. The resident subsequently developed symptoms of aspiration, including cough and congestion, and was transferred to the hospital, where she was diagnosed with aspiration pneumonia and sepsis. Hospital records confirmed the tube feeding rate error and linked it to the resident's acute hypoxemic respiratory failure and subsequent death.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Include PICC Line Care and Management: A resident with pneumonitis, stroke, and hemiplegia had a PICC line observed in the L upper arm, but the admission orders and care plan did not include PICC line care and management. Facility policy required a prescriber order with specific flushing/locking details and documentation of the procedure, and an RN later confirmed the omission.
Failure to obtain physician orders for IV therapy and flush orders affected two residents. One resident had a midline IV for osteomyelitis and was receiving Meropenem, but there was no documented flush order or evidence the line was flushed before and after med administration. Another resident had an IV heparin lock in the forearm, but the MAR showed no physician order for IV therapy and no flush orders; the DON confirmed the orders should have been obtained.
Wrong enteral feeding formula was given to two residents with feeding tubes. One resident with diabetes mellitus and respiratory failure was ordered Nutren 2.0, and another resident with respiratory failure and dysphagia was ordered Isosource 1.5, but staff switched the formulas and administered them to the wrong residents. Interviews confirmed the error, and staff stated LPNs were responsible for checking the physician order and giving enteral feeds one resident at a time.
A resident with dementia, DM2, and chronic venous insufficiency had a PIV and IV medication orders, but the IV flush orders were discontinued while the catheter remained in place. The MAR and order summary showed no current flush orders, and an LPN stated he did not flush the IV because there were no physician orders. The DON verified the flush orders were discontinued and said the IV should have been discontinued at the same time.
A resident receiving IV NS for dehydration had gaps in IV initiation, flush orders, and site monitoring. An RN observed blood in the tubing, flushed the line without cleaning the port, and replaced the bag and tubing, while the record showed missing documentation for IV initiation/discontinuation, no flush or dressing-change orders, and no documented insertion-site assessments during continuous infusion.
PICC Line Dressing Not Changed Within Required Interval: A resident with a PICC line, severe sepsis, and septicemia had an IV dressing on the right arm that remained dated beyond the expected 7-day change interval while receiving IV vancomycin. The resident was unsure how often the dressing should be changed, and both an LVN and the DON stated PICC dressings are expected to be changed every 7 days or as needed if soiled.
Failure to Include PICC Line Care and Management
Penalty
Summary
The facility failed to include care and management of a PICC line for one resident, identified in the report as Resident R181, consistent with professional standards of practice. Facility policy for Central Vascular Access Device Flushing and Locking required a prescriber order for flushing and locking a catheter, including the flushing/locking agent, strength/concentration, volume, and frequency, and required documentation of the date and time, prescribed agent, site assessment, resident response, and teaching. Review of the admission record showed the resident was admitted with pneumonitis, stroke, and hemiplegia, but the admission orders and care plan did not include orders for PICC line care and management. A progress note dated 7/31/26 documented that the resident had a midline in the left upper extremity. On 8/3/26 at 10:30 a.m., the resident was observed lying in bed with a PICC line in the left upper arm, and RN Employee E4 confirmed the PICC line was present during the observation. A later progress note dated 8/6/26 indicated the PICC line was removed from the left upper arm per order. On 8/7/26, RN Employee E4 confirmed the facility failed to include care and management of the PICC line consistent with professional standards of practice for the resident.
Failure to Obtain IV Therapy and Flush Orders
Penalty
Summary
Failure to provide for the safe, appropriate administration of IV fluids occurred when physician orders were not obtained before IV therapy was started for two residents, and flush orders were not documented for either resident. One resident had a midline IV catheter for treatment of osteomyelitis and was ordered to receive Meropenem 2 grams twice daily through July 28, 2026, but the MAR for July 2026 showed no documented order to flush the midline and no evidence that staff flushed the catheter before and after medication administration. A second resident had an IV heparin lock inserted into the right forearm, and a nursing note documented the insertion of a 22-gauge IV catheter. Review of the resident’s July 2026 MAR showed no documented evidence that a physician order was obtained for IV therapy and no flush orders were obtained. The DON confirmed that physician orders should have been obtained for both residents before starting IV therapy and that flush orders should have been obtained.
Wrong enteral feeding formula given to two residents
Penalty
Summary
The facility failed to administer enteral feeding per physician order for two residents by giving each resident the wrong feeding formula. Resident 7 was admitted with diagnoses including diabetes mellitus and respiratory failure, had a feeding tube, and had an order for Nutren 2.0 at 40 mL over 18 hours starting at 2:00 p.m. and stopping at 8:00 a.m. Resident 8 was admitted with diagnoses including respiratory failure and dysphagia, had a feeding tube, and had an order for Isosource 1.5 at 35 mL over 20 hours starting at 2:00 p.m. and ending at 10:00 a.m. The record showed that on 7/12/2026 both residents received incorrect enteral feeding administration. Resident 7’s change of condition evaluation documented that he received an incorrect feeding formula, and Resident 8’s change of condition evaluation documented that he received an incorrect feeding administration. The MARs and order summaries showed the ordered formulas and schedules for each resident, while the documentation and interviews indicated the formulas were switched between the two residents. During interviews, staff stated that the wrong feeding formulas were given and that morning-shift LVNs were responsible for starting and changing feeding formula bags. One LVN stated two feeding formula bags were switched and given to the wrong residents, and another stated Resident 7 received Resident 8’s feeding formula and Resident 8 received Resident 7’s feeding formula. Facility staff also stated licensed nurses were responsible for checking physician orders and administering feeding formulas one resident at a time. The facility’s enteral tube feeding policy stated staff must verify a physician order and check the enteral nutrition label against the order before administration, including the resident name, ID, room number, and type of formula.
Failure to Maintain IV Flush Orders for a Resident with a Peripheral IV
Penalty
Summary
The facility failed to ensure parenteral fluids were administered in accordance with physician orders for one resident who had diagnoses including unspecified dementia, type 2 diabetes mellitus, and chronic peripheral venous insufficiency. Resident #7’s record showed IV medication use, and the care plan identified the resident as having Enhanced Barrier Precautions due to a PIV/surgical wound/pressure ulcer and being at risk for infection, depression, and decline in physical activity. The MAR reflected orders for ceftriaxone IV and for flushing the peripheral IV line with 10 mL of NS before and after each medication and every shift for patency, but those flush orders were discontinued on 7/16/26. On 7/27/26, the resident was observed sitting in a wheelchair with an IV catheter in the right hand; the site had no redness, swelling, pain, or discomfort. Record review showed there were no current orders to flush the IV catheter, and the order summary also reflected no orders to flush the IV catheter. During interview, the LVN stated he did not flush the IV because there were no physician orders and said the IV flush order had been discontinued on 7/16/26. The DON verified that the IV flush orders were discontinued on 7/16/26 and that the IV should have been discontinued at the same time, and stated the floor nurses were responsible for ensuring physician orders were received to maintain IV patency.
IV Fluids Not Initiated and Monitored per Order
Penalty
Summary
The facility failed to ensure safe, appropriate administration of IV fluids for one resident receiving parenteral fluids. During an observation, an RN found blood in the IV tubing while the resident was lying in bed with 0.9% normal saline infusing at 60 cc/hour into a peripheral IV in the right forearm. The RN disconnected the tubing and flushed the line with 10 cc of normal saline without using an alcohol prep pad on the port, then replaced the IV bag and tubing, primed the tubing, and reattached it. The RN later stated she did not use the alcohol prep pad because it was a closed system. Record review showed the resident had dehydration and had been ordered IV fluids on 7/21/26, but there was no documentation that the peripheral IV had been initiated before transfer to the hospital or upon return, no documentation that the IV had been discontinued after the initial bag infused, and no documentation of flush orders or dressing changes. A later order for 0.9% normal saline at 60 cc/hour every shift was entered on 7/26/26, and the MAR showed the fluids were started that night, but there were no documented assessments of the insertion site after the infusion began. The facility policy required verification of the order and indication upon insertion and assessment of the site each shift, before and after medication administration, and during continuous infusions.
PICC Line Dressing Not Changed Within Required Interval
Penalty
Summary
The facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive care plan, and the resident’s goals and preferences for one resident with a PICC line. Resident #4 was admitted with severe sepsis without septic shock, had a Quarterly MDS showing a BIMS score of 9, an active diagnosis of septicemia, and was receiving antibiotics for infection. A physician order dated 06/30/26 directed Vancomycin HCl in NaCl intravenous solution, 500 cc intravenously at bedtime for foot until 8/6/26. During observation on 07/27/26 at 10:57 a.m., Resident #4 was sitting in a wheelchair, clean and well-groomed, and his PICC line dressing on the right arm was dated 07/16/26. The dressing was intact and no redness was noted at the insertion site. The resident stated he was not sure whether it should be dated or how often it should be changed. During interviews, an LVN stated the PICC line dressing should be changed every 7 days or per physician order and that nurses are responsible for following the orders, and the DON stated PICC line dressings should be changed every 7 days and as needed if soiled.
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