Failure to Administer Tube Feeding as Ordered
Penalty
Summary
A deficiency occurred when staff failed to provide enteral nutrition via a gastrostomy tube as ordered by the physician for a resident with significant medical needs. The resident, who had diagnoses including anoxic brain damage, dysphagia, quadriplegia, and was severely cognitively impaired, was dependent on staff for all activities of daily living and received the majority of nutrition and hydration through tube feedings. The care plan and physician orders specified continuous tube feeding at a set rate for 22 hours daily, with a scheduled hold from 12:00 PM to 2:00 PM. However, during an observation period, the tube feeding pump was found not infusing between 11:08 AM and 11:48 AM, outside the scheduled hold time, with the pump screen off and the formula bottle nearly full. Nurse documentation indicated the feeding was administered as scheduled, but direct observation contradicted this. The nurse assigned to the resident was unaware that the feeding was not infusing during the observed period and suggested that a nurse aide may have turned off the pump and forgotten to restart it. The nurse aide interviewed stated she typically only placed the pump on hold during care and did not recall turning it off. Facility leadership confirmed that the feeding should not have been interrupted during this time and that physician orders were not followed.