Failure to Provide Ordered Tube Feeding and PEG Flushes
Penalty
Summary
The deficiency involves the facility’s failure to administer physician-ordered enteral nutrition and PEG tube care for a resident with complex medical conditions. The resident was admitted with diagnoses including anoxic brain damage, acute respiratory failure with hypoxia, nontraumatic intracerebral hemorrhage, seizures, encephalopathy, dysphagia, iron deficiency anemia, gastrostomy status, history of sudden cardiac arrest, CHF, liver disease, and cerebral infarction. A recent MDS assessment showed the resident was unable to complete a BIMS cognitive assessment and required total assistance for hygiene, dressing, repositioning, transferring, and locomotion via wheelchair. Review of the EMR and MAR showed that the resident had a physician order, dated 10/24/25, for Jevity 1.5, 237 mL bolus tube feeding every four hours, and an order to flush the PEG tube with 60 mL of water before and after each bolus feeding and every four hours. On 02/22/26, the MAR documented that the resident did not receive the ordered Jevity 1.5 bolus feedings at 10:00 a.m. and 2:00 p.m., nor the required PEG tube flushes at 10:00 a.m. and 2:00 p.m. This failure occurred despite facility documentation stating that medications are to be administered in accordance with professional standards of practice and the resident agreement stating the right to adequate and appropriate medical and nursing care. The deficiency was investigated under Complaint Number 2793023.
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