Failure to Follow Physician Order for Nighttime Enteral Feeding
Penalty
Summary
The deficiency involves the facility’s failure to follow a physician’s order for enteral nutrition for a resident with significant nutritional and medical needs. The resident had diagnoses including unspecified severe protein-calorie malnutrition, dysphagia, gastritis, cerebral palsy, vitamin D deficiency, and iron deficiency, and required extensive assistance with ADLs. The care plan included a feeding tube and mechanically altered diet, with a physician order for Nutren 2.0 at 65 ml/hr continuously for 10 hours from 8 p.m. to 6 a.m., providing specified calories, protein, and free water, with no end date to the order. Despite this standing order, the resident’s nighttime tube feeding was not administered during the 8 p.m. to 6 a.m. shift on 01/27/2026. The missed feeding was confirmed through record review and staff interviews. A progress note documented that the NP was notified the following morning that the tube feeding had not been done by the night shift nurse. The DON stated that the night nurse did not give the ordered feeding and acknowledged that the nurse should have followed the physician’s order. In an interview, the LVN responsible for the night shift admitted she did not follow the physician’s order and failed to provide the tube feeding, explaining she was confused and thought the feeding was to be done during the day shift and that she should have double-checked the order. The facility’s enteral nutrition policy stated that adequate nutritional support through enteral nutrition is to be provided as ordered, but this was not followed in this instance, resulting in the resident missing the prescribed nighttime tube feeding.
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