F0693

D

Failure to Respond to Tube Feeding Pump Alarms and Follow Enteral Feeding Orders

Farmington, Michigan Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to administer tube feeding according to physician orders for one resident who was ventilator-dependent and received all nutrition via a PEG tube. On multiple observations throughout the same day, the resident’s tube feeding pump was either inactive or alarming, with the pump screen displaying messages such as “Pump inactive. Pump has been idle for 10 minutes” and “Tube slip detected. Remove and reload cassette.” Despite these alarms and error messages, the pump was not restarted or corrected, and the volume of formula in the bottle remained unchanged at 850 ml, indicating that the ordered continuous feeding at 50 ml/hr for 20 hours per day was not being delivered. There were no physician orders to hold the tube feeding.

The resident had diagnoses including COPD, acute respiratory failure with hypoxia, CHF, and dysphagia, required a mechanical ventilator, and did not take any nutrition by mouth, making the PEG tube the sole source of nutrition. The resident’s husband reported that the pump had been alarming all day and he did not know why it was alarming or why a nurse had not addressed it. A respiratory therapist who had been in the room stated she did not notice the alarm and, being new, did not alert anyone. A RN who was not the assigned nurse for the resident stated that nursing staff should be alerted to pump alarms so they can be addressed and acknowledged that a nurse should have been notified. The DON similarly stated that nursing should be made aware of any alarm or error message on a tube feeding pump so it could be reset, and that anyone who noticed it was responsible for reporting it to a nurse. The facility’s policy stated that feeding tubes will be utilized according to physician orders.