Failure to Provide Ordered GT Hydration and Accurate MAR Documentation
Penalty
Summary
The facility failed to provide ordered hydration via gastrostomy tube (GT) for one resident, resulting in insufficient hydration. The resident had cerebral palsy, quadriplegia, dysphagia, severely impaired cognitive skills, and was dependent for all ADLs, and had a GT in place. A physician’s order dated 10/28/2025 directed that the resident receive 60 ml of water every hour for 20 hours per day via GT, totaling 1200 ml of water daily. On observation, there was no enteral feeding pump in the resident’s room to deliver the ordered hourly water. The Registered Dietician confirmed that the current hydration order was 60 ml of water every hour for 20 hours per day via GT. During interviews, LVN 1 stated they had never seen the physician’s order for hourly GT water and confirmed that such an order would normally be administered through a feeding pump, which had not been present in the resident’s room for a long time. The ADON acknowledged that the physician’s hydration order had been overlooked. LVN 2 also reported being unaware of the order and stated they had never seen a feeding pump in the resident’s room. Review of the MAR for the month showed that LVN 2 had documented administering 60 ml of water every hour on multiple dates and shifts, but LVN 2 stated that the resident did not actually receive water every hour and that the MAR entries were marked in error. The facility’s hydration policy required providing hydration based on the physician’s treatment plan and resident condition, which was not followed in this case.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.