Failure to Provide and Document Ordered Enteral Nutrition and Hydration
Penalty
Summary
The facility failed to provide enteral nutrition and hydration as ordered for a resident with complex medical conditions, including anoxic brain damage, osteomyelitis, acute and chronic respiratory failure, mild protein calorie malnutrition, and tracheostomy status. The resident was admitted with physician orders dated January 19, 2026, for continuous Glucerna 1.5 via PEG tube at 60 ml per hour with a total daily volume of 1320 ml, and an additional order for hydration flushes of 40 ml of water every hour with documentation of milliliters in the enteral flush task. Review of the February 2026 MAR showed no documentation that the resident received enteral feeding or medications for the dayshift on February 12, 2026. On observation on February 12, 2026, at 11:20 a.m., the resident’s enteral feeding machine had an empty Glucerna bottle hanging and the pump was beeping. At 11:25 a.m., an RN entered the room, administered medications, and hung a new bottle of Glucerna and hydration fluids. The RN confirmed the enteral feeding should have been continuous. After setup, the pump settings showed a rate of 60 ml with a total feed volume of 1667 ml instead of the ordered 1320 ml. Review of the MARs for January and February 2026 did not show documentation that the resident received the ordered total daily volume of 1320 ml, and review of task forms revealed no enteral flush task documenting the ordered hydration amounts. The Nursing Home Administrator and Director of Nursing confirmed there was no documented evidence that the resident received the prescribed amounts of Glucerna or water.
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