F0693

E

Failure to Provide Ordered Tube Feedings and Safe Positioning During Enteral Nutrition

Saint Louis, Missouri Survey Completed on 11-17-2025

Penalty

No penalty information released

Summary

Surveyors identified that the facility failed to ensure residents receiving tube feeding were provided nutrition as ordered and that tube feeding formula and equipment were properly maintained. One resident with dysphagia oropharyngeal phase had a continuous order for Jevity 1.5 at 65 ml/hr. Multiple observations over several days showed that factory-sealed 1500 ml bottles of Jevity 1.5, labeled with hang times, were not infusing at the ordered rate despite the pump being set correctly. Large volumes of formula remained in the bottles when significant amounts should have infused based on the documented start times and ordered rate, and on at least two occasions the same bottle remained hanging for over 24 hours. The pump was observed alarming “inactive” or “cassette error” with no formula infusing, yet the same bottles continued to hang, and staff did not replace the formula or tubing within the 24-hour timeframe.

The observations for this resident showed repeated instances where the amount of formula remaining in the bottle did not match what should have been delivered according to the physician’s order and elapsed time. For example, a bottle hung the previous evening still had nearly the full volume present the next morning, and later in the day the same bottle continued to show minimal infusion despite the pump being set at 65 ml/hr. On another day, a bottle hung early in the morning still had almost the entire volume remaining several hours later while the pump alarmed with an error and no feeding was infusing. On subsequent observation, the same bottle remained in use more than 24 hours after it was hung, with substantial formula still present when, by calculation, the entire bottle plus additional formula should have infused. Staff interviews confirmed that tube feeding bottles and tubing were supposed to be changed at least every 24 hours and that formula should not hang longer than that.

Surveyors also found that another resident with a history of pneumonia, stroke, and hemiplegia/hemiparesis, who had an order for continuous Jevity 1.5 at 60 ml/hr via pump with allowance for disconnection for care, received personal care while the tube feeding continued to infuse and the head of bed was lowered. On two separate observations, a CNA entered the room, donned gloves, and lowered the resident’s head of bed to provide personal care while the tube feeding continued without being paused. After care, the CNA then repositioned the resident and elevated the head of bed. During one of these episodes, a Wound Nurse was present for a skin assessment and did not pause the feeding or instruct the CNA to avoid lowering the head of bed while the feeding was running. In interviews, nursing staff, including an LPN and the DON, stated that CNAs should notify the nurse so the pump can be turned off during care and that allowing tube feeding to infuse with the head of bed low increases the risk of aspiration.