Failure to Provide Ordered Continuous Tube Feeding to Dependent G-Tube Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a nonverbal, fully dependent resident receiving nutrition and hydration solely via a G-tube received ordered continuous enteral feeding and water flushes. The resident had severe cognitive impairment, was dependent for all ADLs, and had diagnoses including crushing head injury and dysphagia. Physician orders required continuous Isosource 1.5 (or equivalent) via G-tube at a specified rate and duration to meet nutritional and hydration needs. On one evening, beginning at 4:00 p.m., the ordered tube feeding was not initiated and was not provided through the night until 6:00 a.m. the following morning, and there was no documentation that the ordered tube feeding was administered during this entire period. Nursing documentation and progress notes showed that the enteral feed order was placed on hold, with entries on consecutive days indicating the tube feeding remained on hold, but without any documented clinical reason or physician order explaining why it was held. The facility’s investigation identified two RNs as responsible for not administering the tube feeding as ordered. One RN reported that there was no tube feeding formula available in the building and placed the tube feeding on hold, while the ADON and central supply staff reported visually confirming that tube feeding formula was in fact available in the facility that day. The same RN also provided inaccurate information to the oncoming shift that the tube feeding order was on hold. The oncoming RN accepted the report that the tube feeding was on hold and did not verify the physician’s orders or follow up on the actual availability of formula, resulting in the resident receiving no enteral nutrition from late afternoon through the night. Interviews documented that other nursing staff were aware of established processes to obtain formula from central supply, pharmacy, or sister facilities and that tube feedings could only be held with a physician’s order or for specific clinical reasons. The resident’s representative reported being informed that the tube feeding was not administered because the facility ran out of the specific formula and that a similar formula was later initiated, and she described experiencing significant stress, fear, and anxiety upon learning that the resident’s tube feeding had not been provided as ordered.
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