Failure to Administer Ordered PEG Tube Feeding for 48 Hours
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident receiving enteral nutrition via PEG tube was provided tube feeding according to the physician’s order. The resident was admitted with a tracheostomy and PEG tube and had a history of hypertension, hyperlipidemia, and multiple cerebral infarctions. The MDS documented the resident as comatose with no discernible consciousness. Physician orders dated January 19, 2026, directed continuous tube feeding at 60 ml/hr via PEG tube. However, the resident did not receive the ordered enteral formula for approximately 48 hours, during which only water was infused through the PEG tube instead of the prescribed tube feeding. Interviews with staff described how tube feedings were expected to be managed and monitored. RN 1 stated that RNs and LVNs were responsible for managing tube feedings, including checking them at the start of each shift, during designated shut-off times, and at the end of the shift to document intake. The Clinical Coordinator reported that tube feedings were to be monitored during rounds to verify the correct formula, proper labeling, and that the feeding was infusing, and that feeding and water were to be changed every 24 hours. Despite these stated practices, the nursing narrative documented that when the resident was reconnected to enteral feeding, it was discovered that only water had been running through the system and that the pump appeared to be continually flushing with water instead of delivering the ordered formula. Further record review showed that the resident’s weights decreased from 87.2 kg to 85.4 kg over an 11-day period. The nursing narrative documented that the physician was notified that the resident’s tube feeding had not been administered for 48 hours and that only water had been infused via the PEG tube during that time. RN 1 acknowledged that nursing staff should have checked the feeding to ensure it was being administered as ordered and stated that it was important for residents to receive needed nutrition. Review of the facility’s policy, “Guidelines for Management of Enteral and Parenteral Nutrition,” indicated that enteral formula should be initiated at full strength at goal rate if there was no GI compromise. The DON stated that this policy was not followed and confirmed that it was important to meet each resident’s nutritional needs.
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