Failure to Follow Physician's Order for Enteral Feeding Resulting in Aspiration
Penalty
Summary
A deficiency occurred when a nurse failed to follow a physician's order for enteral feeding for a resident with a PEG tube. The physician's order specified that the resident should receive 237 ml of Osmolite 1.5 Cal via PEG tube every four hours, with a flush of 60 ml of water before and after feeding. However, the nurse administered two containers of the formula instead of one during a feeding. This deviation from the prescribed order was confirmed by both the nurse and the Director of Nursing. The resident subsequently developed symptoms including coughing, vomiting, and aspiration, which were reported to the physician. Following the incident, the resident was sent to the emergency room for possible fluid overload and aspiration. Medical documentation indicated that the resident was diagnosed with left basilar pneumonia following a chest x-ray. The resident had a history of esophagitis, dysphagia, and traumatic hemorrhage of the cerebrum, and was cognitively intact at the time of the incident. The facility's policy required verification of physician orders for tube feedings and prompt reporting of complications, but these procedures were not followed in this case.