Failure to Administer and Document Physician-Ordered G-Tube Feedings
Penalty
Summary
Facility staff failed to ensure that a resident receiving supplemental nutrition via a gastrostomy tube (G-tube) was administered tube feedings as ordered by the physician. The resident, who had severe cognitive impairment and was dependent on staff for eating due to dysphagia, had a physician's order for Fibersource HN Oral Liquid to be given through the G-tube four times daily. Review of the Treatment Administration Record (TAR) revealed multiple dates where there was no documentation that the ordered tube feedings were administered. The facility's enteral nutrition policy did not provide specific direction regarding documentation of scheduled tube feedings in the medical record. Interviews with nursing staff, the administrator, and the DON confirmed that staff are expected to document administration of nutritional supplements in the resident's medical record after each feeding. Both the administrator and DON stated that if documentation was missing in the TAR, it was assumed the feeding was not administered. The Regional Director of Operations acknowledged that audits of the TARs to verify completion of documentation had not been performed due to changes in the DON position, resulting in an oversight.