Improper Tube Feeding Administration Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when a severely cognitively impaired resident, who was dependent on staff for all activities of daily living and had a feeding tube due to NPO status and dysphagia, received improper administration of tube feeding. The physician's order specified that the resident was to receive enteral feeding at a rate of 60 ml per hour, but instead, the resident received 800 ml of tube feeding over four hours. This was due to the failure of an LPN to properly set up and monitor the feeding pump, resulting in the tube feeding being administered by gravity rather than through the pump at the prescribed rate. The facility's policy required that all tube feedings be administered by a registered nurse or LPN in accordance with specific procedures, including verifying the physician's order, ensuring the tube is secure, setting the pump to the correct rate, and monitoring the pump's function. However, the LPN did not thread the feeding tube through the pump and did not monitor the feeding pump to ensure it was functioning properly. As a result, the resident received a large volume of feeding in a short period, which was not in accordance with the physician's order. Staff interviews and documentation revealed that the error was not promptly identified. The resident was found with symptoms of respiratory distress and a critically low oxygen saturation level. The resident was subsequently sent to the hospital, where they were diagnosed with aspiration pneumonia and later expired. The facility's failure to follow its tube feeding policy and to monitor the resident appropriately led to this outcome.