Failure to Notify Physician and Document Changes in Enteral Feeding Due to Diarrhea
Penalty
Summary
The deficiency involves the facility’s failure to immediately notify a resident’s physician and representative of a significant change in condition and an alteration in ordered treatment related to enteral nutrition. A female resident with hemiplegia, cerebral infarction, dementia with severe cognitive impairment (BIMS score of 2), and gastrostomy status was receiving tube feeding per physician orders of Glucerna 1.2 at 65 ml/hr with water flushes. She was new to tube feeding following a recent hospital stay and had both daytime bolus feedings and continuous nighttime feedings. The resident’s care plan and orders reflected her dependence on enteral nutrition for hydration and nutrition. On two consecutive nights, the assigned RN independently altered the resident’s ordered tube feeding regimen due to the resident experiencing diarrhea, without notifying the MD/NP and without documenting the change in condition or the withheld treatment. On the first night, the RN stopped the nighttime tube feeding approximately two hours early because the resident had “bad diarrhea.” On the following night, the RN decided not to administer the ordered nighttime feeding at all, stating the resident had “massive diarrhea” and required multiple bed changes. The RN acknowledged she did not call the MD/NP at the time, did not notify them the next morning, and did not document the diarrhea, the early stoppage of the feeding, or the held feeding in the progress notes. Progress notes from other staff during this period also did not reflect diarrhea or any interruption of tube feedings, and there was no documentation of physician notification. The resident’s family, who had a motion-activated camera in the room, reported that the nighttime tube feeding was not running, prompting facility leadership to review video clips. The clips reviewed showed the resident in bed with no feeding bag on the pole and no indication of a feeding running during the relevant nighttime hours, while a CNA provided care and entered the room multiple times. The CNA assigned that night reported not seeing a feeding bag hung or running and stated the resident had multiple episodes of diarrhea since starting the new tube feeding. Interviews with the ADM, RCN, ADON, other nursing staff, and the NP confirmed that the RN did not follow facility policy requiring physician notification and documentation for a change in condition and did not obtain an order to hold the feeding. The NP stated she should have been notified of the diarrhea and that, had she been called, she likely would have agreed to stop the feeding but would have monitored the resident more closely. Facility policies on enteral nutrition and notifying the physician of a change in status required nursing to administer tube feedings as ordered, notify the physician of changes in status, and document signs and symptoms, physician contact, and resident response, which did not occur in this case. Laboratory results drawn during this period showed the resident had low sodium, and the NP later adjusted the water flushes associated with the tube feeding after being informed that a feeding had been missed and one had been stopped early. However, at the time of the events, there was no contemporaneous documentation of the resident’s diarrhea, no record of MD/NP notification, and no record of any physician orders to alter or hold the tube feeding. Interviews with other nurses indicated that their standard practice would be to immediately notify the MD/NP of diarrhea or any change in condition in a resident receiving tube feeding, to obtain orders before holding a feeding, and to document all changes and notifications. The failure to notify the physician and resident representative of the significant change in condition and the need to alter treatment, and the failure to document these changes, constituted the cited deficiency for this resident receiving enteral nutrition.
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