Failure to Provide Ordered G-Tube Feedings Resulting in Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident receiving all nutrition via gastrostomy tube was provided adequate and timely tube feedings to maintain his weight. The resident, an adult male with brain damage from a lightning strike, functional quadriplegia, dysphagia, cognitive communication deficit, and gastrostomy status, was entirely dependent on enteral nutrition and took no food orally per physician orders. During observation, he appeared very thin and frail, and communicated via a communication board that he frequently did not receive his feedings or medications, and that when he did, they were often late. Multiple CNAs reported that the resident had told them he was hungry, that he had lost a lot of weight, and that they rarely or never saw him receive his scheduled early-morning or night-time feedings. The resident’s weight records showed a decline from 114.2 pounds to 98.8 pounds over 38 days, a 13.49% weight loss. A recent hospital discharge summary documented severe protein-calorie malnutrition, a 30% weight loss in less than one year, severe muscle mass loss in specific muscle areas, and described his appearance as cachectic. The December medication administration record (MAR) showed an order for Jevity 1.2, 300 ml every 6 hours via gastrostomy tube at four scheduled times daily. The MAR boxes were largely checked as if feedings were given, with only a few blanks, and the DON stated that if there is nothing documented in the EMAR, the medications or feedings were not given. However, the MAR audit report revealed that many feedings were documented as administered significantly later than scheduled, sometimes hours late, and in some cases signed off days later or even pre-dated as if given before the actual date. Numerous entries showed feedings signed more than three or four hours after the scheduled times, and some early-morning and night-time feedings were not observed by staff on those shifts. The resident’s primary care physician stated he had not been informed of the weight loss or missed feedings and that there was no medical reason for the weight loss other than not being fed. The registered dietician stated that if the resident had received the ordered feedings, he would not have lost weight because the prescribed regimen exceeded his nutritional needs, and concluded that the only reason for the weight loss was that he was not getting enough feedings. The administrator acknowledged awareness that the resident was not being fed as ordered and that he was malnourished.
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