Failure to Follow Enteral Feeding Orders Leads to Aspiration and Hospitalization
Penalty
Summary
A registered nurse (RN) failed to follow physician's orders regarding enteral feeding for a resident with a PEG tube. The resident, who had diagnoses including esophagitis, dysphagia, and traumatic hemorrhage of the cerebrum, had a physician's order for 237 ml of Osmolite 1.5 Cal to be administered via PEG tube every four hours, with a flush of 60 ml water before and after each feeding. Despite documented training on tube feeding, the RN administered two bottles of formula instead of the ordered one bottle during a morning feeding. Following the overfeeding, the resident began coughing and vomiting, eventually aspirating on the formula. The RN notified the physician, who advised holding the next feeding and monitoring the resident. The resident was later sent to the emergency room for possible fluid overload and aspiration. A subsequent chest x-ray confirmed left basilar pneumonia. The Director of Nursing confirmed that the RN did not follow the physician's order, resulting in the adverse event.