Failure to Discontinue Outdated Enteral Feeding Order Resulting in Incorrect Administration
Penalty
Summary
A deficiency occurred when the facility failed to discontinue a previous enteral feeding order after a new order was initiated for a resident with a history of stroke, dysphagia, cognitive impairment, and renal disease. The resident was initially receiving bolus tube feedings as ordered, but due to poor oral intake and refusal of bolus feedings, the Registered Dietician (RD) recommended switching to a continuous enteral feeding regimen. The new order for continuous feeding was entered into the electronic system, but the previous bolus feeding order was not discontinued, resulting in both orders appearing simultaneously on the Medication Administration Records (MARs). As a result, nursing staff continued to administer bolus feedings based on the old order, while the continuous feeding was not consistently provided as per the new order. Multiple staff members, including nurses and medication aides, were unaware of the change to continuous feeding or did not see the new order reflected on their shift's MAR. Documentation inconsistencies were noted, with some staff documenting administration of the continuous feeding when it had not actually been given, and others providing bolus feedings in error. Interviews revealed confusion among staff regarding which order was current, and no one sought clarification until the issue was identified during the survey. The resident's intake varied, but weights remained stable, and there was no reported negative outcome from the failure to implement the continuous feeding as ordered. The deficiency was attributed to the failure to discontinue the outdated bolus feeding order, leading to ongoing administration of the incorrect feeding regimen and lack of proper documentation and communication among staff.