F0580

D

Failure to Notify Physician of Prolonged Interruption in Enteral Nutrition

Madison, Minnesota Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to notify the physician in a timely manner when ordered enteral nutrition and water flushes were not administered due to missing MIC-KEY extension tubing, resulting in multiple missed tube feedings for a resident. The resident was cognitively intact and had diagnoses including anemia, malnutrition, depression, Parkinson’s disease, and chronic vascular intestinal disorders. The resident’s care plan and provider orders directed that tube feedings and free water flushes be administered on specific days of the week, with daily or scheduled weights and provider notification of notable changes. Despite these orders, the EMAR/TAR showed that seven scheduled tube feedings and associated 30 ml water flushes were not given between late December and early January.

Progress notes documented that on multiple dates staff were unable to administer tube feedings, water flushes, or check residuals because the MIC-KEY extension tubing was missing or had been thrown away and no replacement was available. Entries on several days indicated there were no MIC-KEY extensions in the room, no supplies available, and that supplies were on order, with repeated notations that tube feedings could not be given. During this period, the G-tube was not utilized, and staff documented ongoing inability to administer enteral feeds due to lack of equipment. The facility’s central supply process required nurses to write needed supplies on a tablet in the medication room, and MIC-KEY connections were a special-order item not kept in stock, requiring staff notification to the purchasing nurse.

During this same timeframe, the resident experienced weight loss from previously documented weights around 110–112 lbs to approximately 101 lbs and then 100.5 lbs, and the resident reported feeling freezing cold, weak, and like she was dying, leading to an ER visit. The record lacked evidence of provider notification about the missed tube feedings and associated weight loss until a clinic visit with an NP, when it was reported that the resident had not received tube feedings for about 10 days due to the missing connector. Interviews with the DON and LPN staff confirmed that the MIC-KEY connector had been thrown out on Christmas Day, that the written request on the order tablet was missed, that supplies were not received until early January, and that staff would have been expected to notify a provider when unable to administer tube feedings. The facility’s “Change in Condition of Resident” policy required physician and family notification when treatment needed to be significantly altered, with documentation of such notifications in the medical record, but the resident’s record did not show timely physician notification of the missed enteral nutrition.

Interviews with the resident, family member, dietician, and physician further described the circumstances leading to the deficiency. The family member reported being informed by staff that the resident had not received tube feedings since Christmas due to a missing connector and that a similar issue had occurred previously for 10 days. The dietician stated the resident’s oral intake was not adequate and that the feeding tube was needed to keep the resident nourished. The physician later learned that a part had been thrown out, that tube feedings could not be administered, and that the resident’s weight had dropped below 100 lbs, and stated she would have expected immediate notification so that additional orders could be given. Despite these conditions and repeated documentation of missed feedings due to lack of equipment, there was no timely documentation of physician notification as required by facility policy, leading to the cited deficiency for failure to notify the physician of a significant change in treatment and missed enteral nutrition.

The facility’s own policy on change in condition emphasized that nursing judgment must be applied on a case-by-case basis and that staff must contact the physician and notify family when there is a need to significantly alter treatment, including discontinuation of an existing treatment. The ongoing inability to provide ordered tube feedings and water flushes due to missing MIC-KEY extension tubing constituted a significant alteration in treatment, yet the medical record did not reflect timely physician or family notification during the period when feedings were not administered. Only later, after the resident’s weight loss was identified at an outside appointment and after the family raised concerns, was the provider formally notified of the missed tube feedings. This sequence of events, combined with the documented missed feedings and lack of timely notification, formed the basis of the deficiency.