F0692

D

Untimely Processing of Tube-Feeding Water Flush Order Leading to Missed Hydration

Apple Valley, Minnesota Survey Completed on 03-06-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to timely process and implement a physician order for increased scheduled free water flushes for a resident who was NPO and dependent on tube feeding for hydration and nutrition. The resident had Alzheimer’s dementia, severe protein/calorie malnutrition, swallowing difficulties, and had recently been hospitalized for sepsis, pneumonia, and severe dehydration before returning to the facility. Her nutritional assessment identified that her estimated daily fluid needs were 1440–1800 ml, with approximately 821 ml provided by tube feeding formula and the remaining 619–979 ml expected from scheduled free water flushes and medication-related flushes. After readmission, she initially had an order for 150 ml free water flushes six times a day, and on 2/12/26, the RD assessed her fluid needs and obtained a telephone order from a PA to change the regimen to 225 ml free water flushes four times a day via feeding tube, discontinuing the 150 ml flushes.

The RD transcribed the new flush order into the electronic MAR at 12:03 p.m. on 2/12/26, with administration times set for four time windows throughout the day. Based on this entry time, there was potential for the resident to receive the first 225 ml flush between 1:00 p.m. and 2:00 p.m. that day. However, the February MAR showed that the 1:00 p.m.–2:00 p.m. and 4:00 p.m.–6:00 p.m. administration windows on 2/12/26 were marked with an “x” symbol, and the 7:00 a.m.–8:00 a.m., 10:00 a.m.–11:00 a.m., and 1:00 p.m.–2:00 p.m. windows on 2/13/26 were blank, with the 4:00 p.m.–6:00 p.m. window on 2/13/26 documented as “Not Administered: Other Comment: pm shift.” The General Order audit report showed that the new flush order, entered at 12:03 p.m. on 2/12/26, was not verified by LPN-A until 11:16 p.m. on 2/13/26, approximately 35 hours after it was placed. The MAR further identified that the resident did not receive another scheduled free water flush until the morning of 2/14/26 between 7:00 a.m. and 8:00 a.m., following the last documented scheduled flush at 8:00 a.m. on 2/12/26, resulting in an approximate 48-hour gap in scheduled flush administration and a potential 1350 ml fluid deficit related to the untimely order processing.

Interviews with staff revealed inconsistent and delayed order verification practices that contributed to the missed flushes. The RD stated she expected nurses to verify orders the same day and reported she alerted the resident’s primary nurse about the change but could not recall which nurse; she was unaware that multiple flushes were missed. The DON stated that orders entered around midday were expected to be verified within a couple of hours and that the resident’s flush order should have been verified in time for the late afternoon administration window; she acknowledged there was no routine audit process for order-processing timeliness and denied recent audits or identified trends. Multiple nurses and the HUC described a process in which orders were sometimes left unverified for extended periods, with some staff believing the HUC was primarily responsible for processing orders, and others reporting that orders, including dietary orders, could sit in bins or in pending status for days. LPN-A characterized the order process as a “disaster” and reported having encountered orders left unprocessed for up to a week. Staff, including the PA who wrote the order, indicated that the two-day delay in verification of the flush order was longer than expected and acknowledged that the resident, being NPO and dependent on tube feeding, needed the flush order implemented as soon as possible.