Failure to Provide Prescribed Enteral Nutrition Due to Malfunctioning Feeding Pump
Penalty
Summary
The facility failed to ensure proper management of enteral feeding for a resident diagnosed with severe protein-calorie malnutrition and gastrostomy status. The resident was ordered to receive a specific amount of Jevity 1.2 via enteral feeding pump at a continuous rate of 75ml/hr to reach a total of 1,500ml per day, with an NPO (nothing by mouth) diet. Observations revealed that the enteral feeding pump was not functioning properly, as it was found idle and alarming, with no formula being infused for at least 10 minutes. The LPN on duty confirmed that the pump had ongoing errors, resulting in the resident receiving significantly less formula than prescribed—only 1,029ml over 20 hours instead of the required 1,500ml in 24 hours. Further review of the resident's weight records showed a consistent decline, with a 1.75% loss in one month and a 5.16% loss over approximately two months. The staff confirmed that the resident did not receive any oral nutrition due to the NPO order. The facility's enteral tube feeding policy requires nurses to follow physician orders regarding formula type, rate, and duration, but these were not adhered to in this case. The failure to ensure the feeding pump was functioning and to provide the prescribed amount of nutrition contributed to the resident's ongoing weight loss.