Failure to Administer Prescribed Tube Feedings Resulting in Significant Weight Loss
Penalty
Summary
The facility failed to follow physician orders for the administration of tube feeding solution for one resident, resulting in significant weight loss. The resident, who had multiple complex medical conditions including chronic respiratory failure, protein-calorie malnutrition, cerebral palsy, and dependence on a ventilator, was admitted with a gastrostomy and required tube feeding as per physician orders. Observations and record reviews revealed that the resident was very active at night, often crawling on the floor and chewing on the feeding tube, which led nursing staff to disconnect the tube feeding. Despite these challenges, the prescribed tube feeding volumes were not consistently administered as ordered. Medication records showed multiple instances where the resident did not receive the full prescribed amount of tube feeding solution, and on several occasions, feedings were missed entirely. The resident's weight history indicated a significant decrease, with a loss of 31.1 pounds over four months. The registered dietician confirmed that the resident had not received the required caloric intake from tube feedings during the reviewed period and that this issue had been reported to the Director of Nursing. However, there was no documentation or explanation provided for why the resident did not receive the prescribed nutrition, nor was there evidence of corrective action taken by facility leadership following the incident. The failure to administer tube feedings as ordered directly contributed to the resident's significant weight loss.