F0842

E

Failure to Accurately Document Enteral Feedings and Tube Care

Alamogordo, New Mexico Survey Completed on 03-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate medical records for a resident receiving enteral nutrition via a gastrostomy tube. The resident had diagnoses including dysphagia in the oropharyngeal phase and a gastrostomy, and had physician orders for bolus and continuous Jevity tube feedings, scheduled water flushes, residual volume checks, and multiple medications to be given via PEG-tube. Record review of the December MAR showed that staff did not document administration of multiple ordered bolus feedings on numerous specified dates and times. In January, the MAR showed that staff did not document administration of ordered continuous Jevity feedings and scheduled water every six hours on two mornings, despite documenting administration of PEG-tube medications during those same shifts.

Further record review showed that staff also failed to document required enteral tube flushes and residual volume checks on the same dates when medications were recorded as given via the PEG-tube. Specifically, there was no documentation that the tube was flushed with 30 mL of water before and after medication administration and 5–10 mL between medications, and no documentation that residual volumes were checked or what the residual amounts were. During interviews, two LPNs stated they administered the resident’s enteral feedings as ordered, followed all physician orders, and checked residual volumes as required, but these actions were not reflected in the medical record. The DON confirmed that staff did not document multiple bolus feedings in December, did not document continuous feedings, residual checks, or water flushes on the identified January mornings, and stated that staff were expected to follow all orders and document in the medical record.