F0693

D

Failure to Ensure Adequate Tube Feeding Delivery and Bolus Administration

Florissant, Missouri Survey Completed on 02-24-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that residents receiving enteral nutrition via feeding tubes had their nutritional needs met, as required by facility policy. For one resident with a history of stroke, COPD, dysphagia, altered mental status, cognitive communication deficit, and diabetes, the physician ordered Jevity 1.5 at 55 mL/hr via G-tube with 300 mL water flushes every four hours and monthly weights. The resident’s care plan called for monitoring for tube dysfunction or malfunction and for the registered dietitian to evaluate and make recommendations as needed. Weight records showed a decline from 191 lbs on a quarterly MDS to 186 lbs in early February, with a medical director note citing a -7.5% weight loss warning. Despite this, observations over multiple days showed that the tube feeding pump, although programmed at 55 mL/hr, was infusing far less formula than ordered.

On several observation periods, large volumes of Jevity remained in the 1,000 mL bottles despite hours of supposed infusion. On one day, only about 100 mL infused over more than seven hours; on another, about 150 mL infused over more than five hours; and on a third day, about 250 mL infused over more than eight hours. During this time, the pump remained programmed at the ordered rate, but staff did not ensure that the pump was functioning properly or that the ordered volume was actually delivered. A weight obtained with a mechanical lift scale showed the resident at 179.4 lbs with clothing, which was adjusted to 176 lbs after subtracting the clothing weight, indicating further weight loss. The care plan intervention to monitor for tube dysfunction or malfunction was not effectively implemented, as the resident’s tube feeding was leaking and a small hole in the tube was later identified, but only after prolonged periods of inadequate infusion had been observed.

For a second resident with chronic kidney disease, type 2 diabetes, muscle weakness, and severe cognitive impairment, the care plan identified that the resident received alternative nutritional intake via tube feeding with a goal to prevent aspiration. The physician’s order specified enteral feedings of Jevity 1.2, 300 mL per G-tube after meals and at bedtime. Weight records showed a decline from 101.9 lbs to 95.2 lbs, a -6.58% weight loss. Observations over multiple days showed unopened or full 1,000 mL bottles of Jevity 1.2 on the resident’s nightstand, with seals intact or full volumes remaining, indicating that ordered bolus feedings were not being administered as prescribed. An LPN stated that the resident received bolus feedings and claimed to have given a morning bolus using a different bottle, but there was no documentation of the bolus on the MAR, and a CNA who assisted the resident at breakfast reported that the LPN did not administer a bolus while the resident was in the dining room. This demonstrates a failure to provide the ordered bolus feedings and to accurately document their administration for a resident already experiencing weight loss.