F0684

J

Failure to Implement Admission Orders for Medications, Tube Feeding, and Hydration

Elkhart, Indiana Survey Completed on 02-09-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to transcribe and implement physician-ordered medications, nutrition, and hydration for a newly admitted resident. The resident was admitted from a rehabilitation hospital with diagnoses including hemiplegia following a stroke, type 2 diabetes mellitus, gastrostomy, and dysphagia, and was comatose with feeding via a tube. An interdisciplinary team conference note from the sending rehabilitation hospital, provided at the time of admission, listed multiple critical medications and continuous tube feeding with Vital 1.2 at 65 mL/hr and a 25 mL/hr water flush. Despite this, there were no admission orders in the resident’s record from the date of admission until two days later.

Physician orders for the resident’s medications and tube feeding flushes were not written until two days after admission, and the Medication Administration Record (MAR) showed that some medications (glargine insulin, levetiracetam, metformin) were first administered only on that date, with others (aspirin, hydrochlorothiazide, Jardiance, lisinopril) not started until the following day. The MAR documented initiation of Jevity 1.2 tube feeding and water flushes even later, and there was no documentation of any tube feeding, water flushes, or other fluids or nutritional feedings from admission until that time. Care plans addressing altered nutritional status and tube feeding needs were also not initiated until two days after admission, with no care plans in place prior to that date.

A nursing progress note later documented that when a nurse entered the resident’s room to administer medications, the resident was found sweaty, with an oxygen saturation of 85% on room air, no obtainable blood pressure, and a blood glucose monitor reading “HI,” indicating a level beyond the device’s measurable range. Emergency services were called, and hospital records showed the resident had a blood glucose of 954 mg/dL, hypernatremia, extreme volume depletion, and acute kidney injury, and was admitted to a higher-acuity unit for hyperosmolar hyperglycemic state. An RN interview confirmed that, upon auditing the admission orders the Monday after the weekend admission, she discovered that medication, tube feeding, and hydration orders had not been initiated and that there was no documentation of these being provided during the initial days after admission, despite facility policy requiring timely admission evaluation, medication reconciliation, hydration, and 72-hour admission progress notes with vital signs and assessments.

Removal Plan

• Facility staff was in-serviced regarding enteral general nutrition guidelines, laboratory and radiological services, notification of change of conditions, admission evaluations, blood glucose point of care testing, physician orders, clinical morning meeting and admission audits.
• A house-wide clinical assessment of all residents was completed.
• All new resident admissions were reviewed.
• Audits were implemented regarding newly admitted residents.