F0692

D

Failure to Provide Ordered Tube Feedings and Hydration Due to Missing Equipment and Poor Monitoring

Madison, Minnesota Survey Completed on 01-16-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to recognize, evaluate, and address a resident’s nutrition and hydration needs, including failure to administer ordered enteral feedings and water flushes due to missing equipment. The resident had intact cognition, severe protein-calorie malnutrition, abnormal weight loss, muscle weakness, and intestinal disorder, and was care planned to receive tube feedings, free water flushes, and regular diet with monitoring of caloric and fluid intake and weekly weights. Provider orders specified a regular easy-to-chew diet, scheduled tube feedings with a calorically dense formula several times per week, and free water flushes, with later updates increasing tube feeding frequency and initiating daily weights due to weight loss. Despite these orders, the electronic MAR/TAR showed multiple missed doses of the tube feeding formula and free water flushes, as well as some refusals, and the facility did not consistently document or obtain weights as ordered.

From late December through early January, the resident’s tube feedings were not administered for an extended period because MIC-KEY tube extensions needed for feeding were thrown away and no replacements were available. Progress notes documented that from 12/25 through 1/8, the MIC-KEY tube extensions were missing, and on 1/8 it was noted that the extension was still not available and the resident would not drink the supplement orally. During this same period, the resident’s oral intake was poor, with breakfast consistently refused and variable intake at lunch and supper, and the resident experienced significant weight loss, with weights dropping from around 108–109 lbs in mid-December to approximately 99–100 lbs by early January. Weights ordered three times weekly and later daily were not consistently obtained, with several dates lacking documented weights despite active orders related to malnutrition and weight loss.

Staff interviews and documentation revealed that the dietitian, MD, and NP were not promptly informed that tube feedings could not be given due to the missing MIC-KEY connection, and the dietitian was unaware that staff were unable to locate the proper equipment. The dietitian stated that the resident’s oral intake alone had not met nutritional needs for several months and that tube feedings were needed to maintain weight, and that staff should have notified her or the providers if the connection piece was unavailable for more than two days. The MD and NP both stated they would have expected nursing staff to notify a provider immediately when tube feedings could not be administered or were repeatedly refused, and the MD noted that the resident’s weight became concerning when it dropped below 100 lbs. Central supply reported that MIC-KEY connections were not routinely stocked, that ordering depended on nurses notifying purchasing, and that she had not been informed they were out of the connection piece. Nursing staff acknowledged that they should have contacted the on-call provider and nursing leadership when they realized on 12/25 that they lacked the proper supplies to administer tube feedings, especially given the resident’s poor oral intake, shingles, UTI, and noticeable weight loss.

Observations further showed that staff did not consistently promote or assist with fluid intake. During one observation, a nursing assistant placed a 450 ml mug of water next to the resident without offering a drink and left the room. The resident reported being unable to remember if she had received tube feedings, acknowledged sometimes refusing them, and stated she wanted to continue receiving them because she could not eat enough to maintain her weight. The dietitian described that when the resident was well nourished, her mood and participation improved, and that when her weight dropped under 100 lbs, outcomes such as quality of life, longevity, muscle mass, and health were affected. Facility policies required notification of providers for significant changes in treatment and specified that tube feedings be flushed with 30 ml sterile water before and after each feeding, but the facility did not follow these policies in relation to the resident’s missed tube feedings, missing equipment, and declining nutritional status.

The resident’s clinical course during this period included an ER visit for generalized weakness, with findings of tachycardia, weight of 105 lbs, and urinalysis abnormalities suggestive of infection, followed by a diagnosis of generalized weakness and instructions to follow up with the primary provider. Subsequent provider evaluation documented weight loss since the ER visit and revealed that tube feedings had not been given for 10 days due to the missing connector. The NP documented concern about weight changes, inability to provide tube feedings due to the lost connection part or refusals, and lack of timely notification to the provider. Family reported being told that the resident had previously missed tube feedings for 10 days in an earlier month for the same reason and that the resident’s primary source of nutrition and fluids was the tube feeding because she could not eat or drink enough by mouth to meet her needs. Throughout this time, the facility failed to ensure the availability of necessary enteral feeding equipment, failed to administer ordered tube feedings and water flushes, failed to consistently monitor and document weights and intake as ordered, and failed to promptly notify the dietitian and providers of the inability to carry out the ordered nutrition and hydration regimen, resulting in significant weight loss, malnutrition, and weakness as documented in the record.