Failure to Administer and Document Tube Feeding at Ordered Rate for Resident With Pressure Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to administer and document gastrostomy tube feedings at the physician-ordered rate for a resident with unstageable pressure ulcers. Surveyors observed on multiple occasions that the resident’s Jevity 1.5 tube feeding was infusing at 45 cc/hr, despite a physician’s order dated 2/17/26 specifying a continuous rate of 55 cc/hr. The resident’s care plans, both dated 2/3/26, identified the need for enteral feeding to meet nutritional needs and specifically referenced unstageable pressure ulcers on the left buttock and left ischium present on admission, with interventions stating that enteral feeding would be administered as ordered by the physician. Record review showed that the RD’s progress note on 2/9/26 documented an initial tube feeding rate of 45 cc/hr with water flushes and recommended increasing the rate to 55 cc/hr to better meet estimated protein and fluid needs for the resident, who had cerebral palsy and a gastrostomy tube and was receiving more than half of their nutrition and fluids via the tube. A physician’s order was subsequently written to increase the rate to 55 cc/hr. However, the MAR for 2/2026 indicated the tube feeding was documented as being administered at 55 cc/hr on 2/18/26 for all shifts, which conflicted with surveyor observations of a 45 cc/hr rate, and there was no documentation of tube feeding administration on the 2/19/26 day shift. The facility’s feeding tube policy required licensed nurses to implement physician orders for enteral therapy, which was not followed in this case.
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