Failure to Follow Physician Order for Enteral Feeding Rate
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders and professional standards of quality for a resident receiving enteral nutrition. The resident is an adult male with multiple complex diagnoses, including malignant neoplasms, COPD, chronic kidney disease, peripheral vascular disease, gait and mobility abnormalities, gastrostomy status, and several psychiatric conditions. His BIMS score of 11 indicated moderate cognitive impairment. According to the Medication Administration Record for January 2026, the physician’s order dated 01/07/2026 specified continuous enteral feeding with Osmolite 1.5 at 80 ml/hr for a total feed volume of 1920 ml over 24 hours, with water flushes at 40 ml/hr for a total flush volume of 960 ml over 24 hours. Facility policy for enteral tube feeding care required the nurse to check the POS/MAR for the enteral feeding order, including formula, type, rate, and duration. On 01/17/2026 at 10:48 a.m., the resident was observed awake and alert in bed with the gastrostomy tube feeding infusing at 100 cc/hr of Osmolite 1.5. The resident stated that the nurse had changed his feeding rate to 100 earlier that morning. At 12:18 p.m., the feeding was still infusing at 100 cc/hr. At 12:20 p.m., an agency RN (V15) confirmed to the surveyor that the feeding pump was set at 100 cc/hr. After reviewing the resident’s order in the electronic record (PCC/PointClickCare), V15 acknowledged that the ordered rate was 80 cc/hr and stated that the rate needed to be changed to match the doctor’s order. At 12:25 p.m., V15 adjusted the feeding rate from 100 cc/hr to 80 cc/hr, stating that they were supposed to follow the physician’s order. This sequence of events shows that the resident received enteral feeding at a rate higher than ordered, contrary to the facility’s enteral feeding policy and the job descriptions for floor nurses, which require adherence to physician orders and established nursing policies and procedures.
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.