F0684

E

Failure to Follow Physician Orders for Tube Feeding, Weights, and PRN Diuretics

Orwigsburg, Pennsylvania Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders for treatments and monitoring for four residents. For one resident with a history of stroke, aphasia, dysphagia, and an enteral feeding tube, a physician ordered 100 ml water flushes every six hours. Observation of the enteral feeding pump showed it was programmed to deliver 175 ml water flushes every six hours, and the DON confirmed the pump was not set to the correct volume. Another resident with encephalopathy, type 2 diabetes, and cellulitis of the lower left leg had an order for daily weights and PRN torsemide to be given if weight increased by 2 lbs in 24 hours or 5 lbs in a week. The MARs showed multiple days where no weights were recorded, and documented weights reflected several qualifying weight gains without any documented administration of torsemide as ordered.

A third resident with emphysema and chronic congestive heart disease had a physician’s order for daily weights to monitor the resident’s condition, but the MARs showed multiple dates where no weights were recorded. A fourth resident with congestive heart failure, intestinal obstruction, and diabetes had orders for daily weights and PRN furosemide 40 mg for weight gains of 2 lbs in one day or 5 lbs in one week, along with a care plan noting a nutritional problem related to fluid shifts and interventions including fluid restriction and medication administration as ordered. The weight records showed repeated instances of 2 lb or greater gains in one day without any documented evidence that furosemide was administered. The DON confirmed that the PRN furosemide was not given for the documented weight gains and that weights and medications were not administered or recorded as ordered for the affected residents.