Failure to Properly Manage and Document Feeding Tube Administration
Penalty
Summary
The facility failed to properly manage and document the administration of feeding tube nutrition for a resident with multiple complex medical conditions, including type 2 diabetes, dysphagia, functional quadriplegia, and dementia. The resident had a PEG tube for enteral feeding, with physician orders specifying the type, rate, and total volume of nutrition to be administered, as well as instructions for tubing changes and documentation. Observations and record reviews revealed that the prescribed feeding regimen was not consistently followed, with documented amounts of nutrition administered frequently above or below the ordered total, and numerous instances of missing or inconsistent documentation regarding the volume infused. There were multiple occasions where the feeding pump malfunctioned or was not properly monitored, resulting in the resident not receiving the required nutrition. This led to episodes of hypoglycemia, as evidenced by low blood sugar readings and the need for emergency interventions such as oral glucose and glucagon administration. Staff interviews confirmed that there were issues with the feeding pump not functioning correctly, and that staff had not received recent education on the use of feeding tube pumps. Additionally, documentation practices were inconsistent, with repeated or decreasing totals recorded and significant gaps in the required two-hourly documentation of infused amounts. Nursing management and the DON were made aware of the issues after family concerns and direct observations of the resident not receiving the correct amount of feeding. Despite the implementation of more frequent checks, there remained missing documentation and continued inconsistencies in the administration and recording of tube feedings. The facility was unable to provide evidence that the resident consistently received the prescribed amount of nutrition, and staff were unable to explain discrepancies in the records.