F0693

E

Failure to Maintain Continuous Enteral Feeding as Ordered

Wichita Falls, Texas Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

A resident with Parkinson’s disease, moderate protein-calorie malnutrition, dysphagia, aphasia, and quadriplegia, who received all nutrition via continuous enteral feeding, did not receive ordered tube feeding for approximately two hours. The resident had a physician’s order for Jevity 1.5 at 70 cc/hr with water flush at 50 cc/hr for 22 hours each day. On the day of the incident, the resident’s feeding pump began beeping when the feeding bag ran out at about 2:30 p.m. A CNA reported the beeping pump to an RN while the assigned LVN was on break. The RN stated she informed the LVN when the LVN returned from break at 3:30 p.m., and the LVN acknowledged this. Later, at about 5:30 p.m., another CNA again reported to the LVN that the resident’s feeding pump needed to be changed, and the LVN again acknowledged the report.

Despite these reports, the LVN did not replace the feeding bag before the end of her shift. She stated she was on her way to change the bag after the 5:30 p.m. report but was diverted to assist another resident and did not complete the task. At shift change at 6:00 p.m., she told the oncoming LVN that the resident’s feeding pump needed to be changed, and he said he would take care of it. Review of the medication administration record showed the resident’s enteral feeding was documented as given on the night shift, and a one-time bolus feeding was ordered later that evening due to an extended period without feeding. The facility’s enteral nutrition policy stated that adequate nutritional support through enteral nutrition is to be provided as ordered and that nursing staff and providers monitor for signs and symptoms of inadequate nutrition. The facility determined that the resident did not receive enteral feeding for approximately two hours, which failed to ensure continuous enteral nutrition as ordered.