Failure to Administer Tube Feeding at Physician-Ordered Rate
Penalty
Summary
The deficiency involves the facility’s failure to administer tube feeding according to the physician’s ordered rate for a resident receiving enteral nutrition. The resident had multiple significant diagnoses, including COPD, cerebral infarction with aphasia, hemiplegia and hemiparesis, abnormal weight loss, and multiple pressure ulcers, and was dependent on staff for eating with a feeding tube in place. The resident’s comprehensive person-centered care plan and current physician orders dated 02/17/2026 specified Fibersource tube feeding at 60 ml/hr. Departmental progress notes documented a recommendation and a new order on 02/17/2026 to increase the tube feed to Fibersource at 60 ml/hr. Despite these orders, multiple observations on consecutive days showed the resident’s tube feeding infusing at 55 ml/hr via pump. On 02/23/2026 at 10:45 a.m. and 4:08 p.m., and again on 02/24/2026 at 8:25 a.m. and 12:25 p.m., the tube feeding rate remained at 55 ml/hr. During an interview on 02/24/2026 at 12:50 p.m., an LPN confirmed that the tube feeding was set at 55 ml/hr and acknowledged it should have been at 60 ml/hr per the physician’s order. This discrepancy between the ordered rate and the administered rate constituted the failure to ensure the resident’s tube feeding was provided as prescribed.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.