F0684

G

Failure to Provide Ordered Enteral Nutrition and Honor POLST for Artificial Nutrition

Elmwood Park, Illinois Survey Completed on 03-29-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide ordered enteral nutrition and hydration, to follow tube-feeding policies, and to honor an existing POLST directive for artificial nutrition and hydration. One resident (R11) had a history of anoxic brain damage, severe protein-calorie malnutrition, acute and chronic respiratory failure, stage 4 sacral pressure ulcer, tracheostomy, and gastrostomy status, and was assessed as severely cognitively impaired and dependent for all ADLs. His care plan documented NPO status with enteral feeding for all nutrition needs, including monitoring tolerance, weight, labs, skin, hydration, and providing additional fluids via feeding tube as ordered. Physician orders included a nutritionist consult after emesis and instructions to check residuals and hold feeding if residuals were ≥100 ml, with MD notification if residuals remained high. However, at the time of surveyor observations, R11 had no active G-tube feeding order, only water flush and medications, and was repeatedly observed in bed with a G-tube plunger at bedside, no feeding pump, and no feeding infusing.

Staff interviews revealed that R11’s feeding had been stopped by hospice on a prior date due to episodes of emesis and perceived respiratory distress. The hospice RN stated that R11 had been on 2 cal formula at 50 ml/hr with a total volume of 425 ml and that hospice discussed with the family that feeding could cause respiratory distress; no other interventions such as reducing rate or volume were attempted before stopping feeding entirely, and hospice believed the resident was near end of life. The hospice RN acknowledged telling the POA that at end of life the resident did not need feeding. The POA reported having no clinical experience, relying on hospice’s explanation, and believing that because the resident was at end of life he did not need feeding; she also stated the resident did not receive water except with medications and was not being turned and repositioned every two hours as care-planned. The facility dietitian reported she was not notified that feeding had been stopped, described not feeding at all as “extreme,” and stated that the facility should be following the resident’s POLST form when determining care.

R11’s Illinois Department of Public Health POLST form, signed by the POA, documented in section D that artificial nutrition and hydration should be provided by any means, including new or existing surgically placed tubes. The DON stated she was not aware that R11’s feeding had been discontinued and agreed the facility should follow the POLST. The attending physician/medical director acknowledged being aware that hospice had stopped the feeding due to aspiration risk and that the longer the resident was fed, the longer he would live, and stated that if the G-tube feeding was discontinued, the POLST should be readdressed and a new form obtained. The facility’s advance directive/DNR policy stated that life-sustaining treatments include IVs, tubes, and artificial hydration and nutrition to maintain life unless there are specific directions from the resident or family not to, and that changes to advance directives require voiding the old form and initiating a new one. No documentation was presented showing that R11’s POLST had been revised to reflect a decision to withhold artificial nutrition and hydration.

A second resident (R1) with acute and chronic respiratory failure, type 2 diabetes, protein-calorie malnutrition, dysphagia, a stage 3 pressure ulcer, traumatic brain injury, epilepsy, encephalopathy, tracheostomy, and gastrostomy status was also affected. R1’s MDS documented severe cognitive impairment and that more than 51% of nutrition was via enteral feeding. The care plan indicated R1 was NPO due to dysphagia, that tube feeding would provide approximately 100% of estimated needs, and that staff should monitor tube-feeding tolerance; it also noted R1’s increased risk of abuse due to fragility, poor cognition, and poor communication, with a goal to remain free from mistreatment. Physician orders specified continuous enteral feeding of 2 Cal HN at 40 ml/hr for 20 hours daily (on at 2 pm, off at 10 am) via G-tube, with Jevity 1.5 as a substitute at 52 ml/hr for 21 hours if needed.

During observation, R1 was found in bed, unarousable, with the enteral feeding pump alarming “FEED ERROR.” The feeding carton was completely desiccated, with only a quarter-sized amount of dried, cracking formula inside, and the tubing contained dry residual formula occupying less than 10% of its length. The carton was labeled with a date indicating it had last been hung two days earlier, with no time noted. Nursing staff and the DON confirmed that at the ordered rate of 40 ml/hr, the 1-liter carton would last approximately 25 hours and that another carton should have been hung the previous day. The DON acknowledged that R1 was completely dependent on staff for enteral feeding and hydration. There was no documentation in the medical record between the date the carton was hung and the survey date indicating that feeding had been held, that a provider had been notified, or that any rationale existed for not administering the feeding.

Progress notes for R1 documented on a later date that the resident was in bed with head of bed elevated, vital signs stable, medications given, and “GTF ongoing, on at 2pm off at 10am,” with trach and G-tube sites intact and no signs of infection, and that the resident was repositioned every two hours. This documentation did not reflect the observed absence of active feeding or the dry feeding set. The dietitian confirmed that R1 was NPO and that 100% of nutritional needs were delivered via tube feeding, and explained that the current order met 100% of estimated needs. The medical director stated that a patient with diabetes who does not receive ordered enteral feeding could be expected to develop hypoglycemia, dehydration, or electrolyte imbalances. Nursing staff assigned to the unit on the relevant shifts either denied being assigned to R1, did not recall the resident, or stated they did not change tube-feeding cartons, indicating that night shift was responsible for changing sets at midnight and dating them accordingly.

The facility’s Tube Feeding Management policy required continuous tube feedings to be based on a 22-hour consumption period or other time frame per RD assessment, with the health care provider notified if the ordered amount was not infused, and required labeling of tube feedings with resident name, rate, total volume, date, and time hung. The policy also required that the pump be cleared at the end of each shift, that tube feeding delivered be documented, and that the health care provider be alerted to any issues or concerns. In R1’s case, the feeding set remained in place well beyond the expected infusion period without replacement, the pump alarmed without effective response, and there was no documentation of the interruption or of provider notification. In R11’s case, enteral feeding was discontinued without updating the POLST or notifying the dietitian, despite the existing POLST directive to provide artificial nutrition and hydration by any means.