Failure to Administer and Document Enteral Feeding per Physician Orders
Penalty
Summary
The facility failed to ensure that a resident with a gastrostomy tube (GT) received enteral feeding as ordered by the physician and that the administration of the feeding was properly documented in the Medication Administration Record (MAR). Specifically, the resident had physician orders for TwoCal HN, a calorie and protein-dense nutritional supplement, to be administered at set intervals. However, review of the MAR revealed that the enteral feeding was not documented as administered on multiple occasions, and staff interviews confirmed that nurses sometimes forgot to sign the MAR after giving the feeding. In some instances, the feeding was delayed at the request of the resident's family, but documentation was still incomplete or missing. Facility policies required that all procedures related to enteral feeding, including verification of tube placement, amount and type of feeding, and resident response, be recorded in the medical record. Additionally, all services provided were to be documented to facilitate communication among the care team. Despite these policies, the MAR was left blank on several dates, and staff acknowledged that they may have forgotten to sign after administering the feeding. The Director of Nursing confirmed that the MAR should not be left blank and that refusals or delays should also be documented.