Inaccurate Measurement of Physician-Ordered Tube Feeding Volume
Penalty
Summary
The facility failed to ensure accurate measurement and administration of physician-ordered tube feeding for a resident receiving bolus enteral nutrition. The resident had a feeding tube, was NPO, and had an order for Jevity 1.5 cal with fiber, 240 ml via feeding tube five times daily, totaling 1,200 ml per day, for nutrition support related to esophageal dysphagia that had led to malnutrition. During observation of a scheduled tube feeding, an RN used a 30 ml medicine cup and a 120 ml drinking cup to measure the formula instead of the syringe provided for accurate measurement. The RN repeatedly filled the 30 ml cup without verifying the volume at the marked 30 ml line and poured these unmeasured amounts into the drinking cup, which was not filled to the 120 ml level, and then administered the contents via the feeding tube. She stated this was her usual method for administering the resident’s tube feedings. Record review and subsequent measurement of the formula bottles by the DON showed that each bottle contained 1,000 ml and that the bottle used for the observed feeding had been opened the previous day before the resident’s 5:00 PM feeding. The feeding observed was the fifth feeding from that bottle, and based on the ordered regimen, the bottle should have been depleted and an additional 200 ml from a new bottle should have been required if the correct volumes had been administered at each feeding. Instead, only approximately 60 ml from the new bottle was used, indicating that the resident’s tube feeding at that time was short by about 140 ml. The DON confirmed that the resident did not receive the correct amount of tube feeding formula as ordered by the physician and that nurses were expected to use the provided syringe to accurately measure tube feeding volumes, consistent with the facility’s enteral nutrition policy, which requires administering the ordered amount of feeding.
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.