Failure to Administer Tube Feeding per Physician Order Resulting in Aspiration Pneumonia
Penalty
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.