Failure to Administer Enteral Feeding at Physician-Ordered Rate
Penalty
Summary
A deficiency occurred when a nurse failed to administer enteral feeding formula at the correct rate as ordered by the physician for a resident with dysphagia, gastrostomy for enteral feedings, malnutrition, and vascular dementia. The resident's physician order specified continuous enteral feeding via a pump at 130 ml per hour for 12 hours overnight, with water flushes of 50 ml every 4 hours. During an observation, the nurse programmed the feeding pump incorrectly, setting the formula to infuse at 50 ml per hour and the water flushes at 130 ml every 4 hours, contrary to the physician's orders. The error was identified when the nurse was asked to verify the physician's order and realized the settings were incorrect. The nurse then re-entered the resident's room and adjusted the pump to the correct settings as per the physician's order. The Director of Nursing confirmed that the enteral feeding pump should have been set according to the physician's instructions. The deficiency was based on the failure to follow the prescribed enteral feeding and water flush rates for the resident.