Abusive Administration of Tube Feeding Flush Despite Resident Refusal
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse and to honor the resident’s right to refuse treatment during enteral feeding care. The resident was admitted with hemiplegia and hemiparesis following cerebral infarction, malnutrition, facial weakness, and dysarthria, and had a PEG tube due to dysphagia and dependence on staff for eating. A care plan and enteral feeding order directed Jevity 1.5 bolus feeds every four hours with a 50 mL purified water flush after each feeding. Documentation showed the resident occasionally became confused and resistive with care, including PEG tube care, and had been known to reject care. On one occasion, a behavior note documented that during a bolus feeding the resident became combative, pushed the nurse’s hands away, and said “no more food and water,” after which the LPN explained the need for the water flush and the resident agreed to the flush. A subsequent behavior note recorded that at a midnight bolus feeding, the LPN, assisted by two CNAs, proceeded with the bolus and water flush while the resident tried to kick staff and push the food away, repeatedly saying “no more food, no more water.” During this episode, the two CNAs held the resident’s hands and knees down while the LPN administered the bolus and flush. A later note the same night documented that the resident refused food and the bolus was not given. The resident’s admission MDS showed a BIMS score of 14, indicating cognitively intact status, and confirmed dependence on staff for eating and use of a PEG tube, with a history of rejecting care. In an interview, the resident reported refusing multiple times by pushing the tube away and verbally stating he did not want the treatment or the flush because it caused him to go to the bathroom, and stated that when he tried to push it away, the nurse brought more staff to hold him down while she flushed against his wishes. Personnel and termination documents for the LPN and both CNAs indicated that they participated in resident abuse by forcefully administering treatment and physically holding the resident’s extremities so that the tube feeding flush could be given despite the resident’s clear refusals. Facility policies in effect at the time stated that residents have the right to be free from abuse, including physical restraint not required to treat medical symptoms, and the right to request, refuse, and discontinue treatment.
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