F0693

D

Incorrect Enteral Feeding and Hydration Rates Not Following Physician Orders

Erie, Pennsylvania Survey Completed on 03-31-2026

Penalty

No penalty information released

Summary

The facility failed to provide enteral nutrition and hydration in accordance with physician orders for one resident receiving tube feeding. Facility policy on enteral tube feeding via continuous pump required staff to check the enteral nutrition label against the order before administration, including verifying the rate of administration in mL/hour. The resident, admitted with diagnoses including cerebral palsy, chronic respiratory failure, and a gastrostomy, had physician orders dated 12/31/25 for continuous pump feeding of Peptamen AF at 55 cc/hr and a hydration flush at 70 cc/hr over 24 hours.

On multiple observations on 3/23/26 at 10:30 a.m., 12:30 p.m., and 1:25 p.m., the resident was observed in bed receiving enteral feeding via g-tube with the feeding pump set at 50 cc/hr and the hydration flush set at 80 cc/hr, which did not match the physician’s orders. During an interview at 1:30 p.m. the same day, an RN confirmed that the feeding rate and hydration flush settings were 50 cc/hr and 80 cc/hr, respectively, and acknowledged that these settings were not in accordance with the resident’s physician orders and should have been set per those orders.