F0693

D

Failure to Follow Enteral Feeding Orders and Label Feeding Containers

Niles, Illinois Survey Completed on 11-21-2025

Penalty

No penalty information released

Summary

The deficiency involves failure to administer enteral tube feeding according to physician orders and failure to label an enteral feeding container per facility policy. One resident’s tube feeding was observed infusing at 55 ml/hr in the morning and again at midday, while the physician’s order specified a rate of 65 ml/hr of a 1.5 nutritional supplement every shift. The LPN confirmed that the rate should have been set at 65 ml/hr per the order, and the DON later stated that staff are expected to carry out orders as prescribed and that the rate should have been 65 ml/hr. This resident is an 80-year-old male with a history including malignant neoplasm of the prostate, Parkinson’s disease without dyskinesia, multiple rib fractures, and gait and mobility abnormalities, and had an active order for enteral feeding at 65 ml/hr.

A second resident with a gastrostomy tube and diagnoses including diffuse traumatic brain injury with loss of consciousness, encounter for attention to gastrostomy, and unspecified oropharyngeal dysphagia was observed in bed with enteral feeding running at 50 ml/hr, consistent with the physician’s order for 1.5 nutritional supplement at 50 ml/hr for 21 hours or until 1050 ml total volume infused. However, the enteral feeding bag in use had no visible identification label. The Wound Care Coordinator stated that feeding bags should be labeled with the resident’s name, date, start time, rate, and volume to infuse per the physician’s order before administration. The DON also stated that enteral feeding containers should be labeled for identification and proper administration. The facility’s “Gastrostomy Tube – Feeding and Care” policy requires the licensed nurse to review the physician’s order for formula type, concentration, rate, and method, and to label the container with the resident’s name, flow rate, date, and time.