F0692

D

Failure to Administer G-Tube Feeding per Physician Orders

Avon, Indiana Survey Completed on 02-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident who received all nutrition via G-tube was provided tube feedings in accordance with physician orders. Surveyors observed that the resident’s feeding pump, set up next to the bed, was not running on the morning of 2/2/26, with approximately 800 ml remaining in a 1000 ml bag of IsoSource 1.5 that was labeled as started at 2:15 a.m. Review of the medical record showed an active order, dated 1/29/26, for Glucerna 1.5 at 75 ml/hr for 20 hours per day, from 4:00 p.m. to 12:00 p.m. the following day, with no special instructions allowing substitution of another formula. The resident was a long-term care resident with traumatic brain injury and dysphagia and was known to have weight loss, relying entirely on G-tube feedings for nutrition.

Later that day, the resident was observed sitting in a Broda chair with the G-tube tubing connected, but the pump was turned off, and only about 100 ml less formula was in the bag than at the earlier observation. The Unit Manager stated the tube feeding was not running because it was past the ordered stop time of noon. The DON stated IsoSource should only be used instead of Glucerna if Glucerna was unavailable and that any substitution required NP approval, and she was unsure why there was 400 ml more than expected in the bag, speculating that the night nurse may have spiked a new bag early. However, the LPN who started the tube feeding on night shift stated that the time written on the bag was the time the feeding was actually started. A dietician quarterly assessment note allowing substitution of IsoSource for Glucerna if Glucerna was unavailable was documented later, on 2/2/26 at 2:50 p.m., after the observations.