Failure to Follow Enteral Feeding Orders for Two Tube-Fed Residents
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for enteral nutrition for two residents with gastrostomy tubes, resulting in incorrect feeding rates, durations, and total volumes. For the first resident, an adult male with chronic respiratory failure, a gastrostomy tube, developmental disorder of speech and language, and congenital hydrocephalus, the physician’s order specified Pediasure Peptide at 150 ml/hr for a total volume of 240 ml twice daily. The Enteral TAR reflected these same orders. However, a nurse reported that she relied on a pre‑printed label on the feeding bag, which indicated a rate of 240 ml/hr with a total volume of 360 ml, and she set the pump accordingly. On the day of observation, the pump was found set at 240 ml/hr with 240 ml already administered, and the nurse stated she had used the same settings the previous day and that the school staff did not change pump settings. The nurse caring for the first resident acknowledged that she did not verify the pump settings against the physician’s orders and instead followed the pre‑printed label, which did not come from the pharmacy. She stated that she had administered the resident’s enteral feedings at 240 ml/hr with a total volume of 360 ml at both scheduled times on the prior day and that the school would have administered the morning feeding at the same incorrect rate and volume because she had pre‑set the pump. Another nurse stated that she checked the MAR against pre‑printed labels because the MAR was always accurate and the labels were not, and she confirmed that administering a feeding at 240 ml/hr instead of the ordered 150 ml/hr could cause abdominal discomfort and vomiting. Facility leadership, including the ADON and DON, confirmed that the resident’s feeding rate had been set too high and that staff should have followed the enteral orders rather than the pre‑printed label. For the second resident, an adult female with spastic quadriplegic cerebral palsy, gastrostomy, protein‑calorie malnutrition, feeding difficulties, ventilator dependence, dysphagia, and no speech, the physician’s order specified Compleat Pediatric Reduced Calorie at 68 ml/hr by gastrostomy tube for 18 hours with a total volume of 1174 ml. The Enteral TAR documented administration at 68 ml/hr for 18 hours with a total volume of 1174 ml daily. During observation, the resident’s feeding pump was infusing at 68 ml/hr for 17 hours, and the pre‑printed label on the feeding bag read 68 ml/hr for 17 hours with a total volume of 1156 ml. A nurse stated that this resident was not assigned to her that day and, after checking, reported that the order was for 68 ml/hr for 18 hours and that the total volume on the order itself had also been calculated incorrectly and should have been 1224 ml. She explained that with the pump set for 17 hours instead of 18, the resident would not receive the full ordered amount of feeding. The nurse who set up the second resident’s feeding stated that night shift prepared feeding bags with pre‑printed labels and that she set the pump according to the label. She acknowledged that feeding orders sometimes changed and that staff were supposed to look at the MAR and Kardex and receive updates in report when changes occurred. She stated that the nurse was responsible for ensuring that what was administered matched the physician’s orders and that if the resident did not receive the prescribed amount of feeding, she could lose weight. The ADON for the resident’s unit reported that the resident had returned from a doctor’s visit with a new order to increase feedings to 18 hours and that the nurse who received the order did not enter the total volume correctly. The DON confirmed that the label for this resident had not been updated when the new order was entered and that, if the total volume and duration were incorrect, the resident would not receive the correct amount of feeding. The facility’s Enteral Nutrition policy required that nurses confirm that enteral nutrition orders were complete, including volume and rate of administration, and that staff caring for residents with feeding tubes be trained to recognize and report complications such as nausea, vomiting, diarrhea, abdominal cramping, inadequate nutrition, and aspiration.
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