Failure to Monitor Enteral Nutrition Leads to Significant Weight Loss
Summary
The facility failed to ensure proper oversight of a resident receiving nutrition through an enteral tube feed, resulting in a significant weight loss of 7.5% over six months. The resident, who was severely cognitively impaired and dependent on eating, had a history of cerebral palsy, dysphasia, aphasia, and feeding difficulties. Despite physician orders for weekly weight checks and specific enteral feeding instructions, the facility did not adequately monitor the resident's nutritional intake or document the amount of tube feeding received. Observations and interviews revealed that the resident's feeding pump frequently malfunctioned, turning off without staff being aware due to inaudible alarms. Staff interviews indicated that there was no consistent documentation of the residuals or the actual amount of nutrition the resident received. The resident's weight was inconsistently recorded, with discrepancies noted between weights taken using different methods, such as a mechanical lift and a wheelchair. The facility's policy on enteral nutrition required complete orders and confirmation of tube placement and gastric residual volume, but these were not consistently followed. The Director of Nursing and Diet Technician were unaware of the feeding pump issues, and there was no notification to the dietitian about the resident not receiving the prescribed tube feed. This lack of communication and documentation contributed to the resident's significant weight loss and the facility's failure to meet the resident's nutritional needs.
Penalty
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Surveyors found that two residents receiving enteral nutrition via gastrostomy tubes had tube feeding products and water in use without required labeling. For one cognitively intact resident with multiple conditions including diabetes, malnutrition, and gastrostomy status, an LPN used an enteral formula that had been poured out of its original container into an unlabeled feeding bag, along with an unlabeled water bag, then connected both to the resident and started the pump without documenting date, time, formula type, or rate on either bag. For another resident with post-stroke hemiplegia, dysphagia, malnutrition, and a gastrostomy, the water bag used for hourly flushes was actively running but lacked date and time labeling, despite physician orders requiring each new feeding and water bag to be labeled with name, date, time, and hourly rate. Nursing staff interviews confirmed that these bags should have been individually labeled and were not.
A resident with multiple complex conditions, including dementia, dysphagia, and dependence on G-tube feeding, had physician orders for continuous tube feeding, scheduled water flushes, and daily cleansing of the G-tube site with application of a sponge dressing. During observation, an LPN found the G-tube site without the ordered dressing and cleaned brown/red dried drainage from the insertion area, acknowledging that a dressing should have been in place. The DON later reported there was no formal facility policy or procedure for G-tube care and maintenance, even though additional residents also had G-tubes.
A resident with a gastrostomy tube, dementia, hemiplegia, dysphagia, and epilepsy was observed receiving the wrong tube feeding formula. The physician ordered Isosource HN at 80 ml/hr, but the resident was found on Fibersource HN at the same rate, and an LPN confirmed the formula mismatch and said the bag had been hung by the previous shift.
A resident with multiple serious conditions, including anoxic brain damage, respiratory failure, dysphagia, and gastrostomy status, had physician orders for Jevity 1.5 bolus tube feedings every four hours and PEG flushes with 60 mL water before and after each feeding and every four hours. EMR and MAR review showed that on one day the resident did not receive the ordered bolus feedings or PEG flushes at two scheduled administration times, contrary to physician orders, the facility’s medication administration policy, and the resident’s right to adequate and appropriate medical and nursing care.
Tube Feeding Not Provided as Ordered: A resident with a feeding tube, impaired cognition, dysphagia, and multiple chronic conditions did not receive the full ordered tube feeding. An LPN hung a 1-liter bottle of Jevity 1.2, and the next morning the bottle was empty and the pump was off; the LPN confirmed the resident received only one liter instead of the ordered 1260 ml and stated a second bottle should have been hung.
A resident with dysphagia, severe protein-calorie malnutrition, and hemiplegia had a tube-feeding container hung without the required label, date, or nurse initials. The active MD order required the formula container, syringe, and admin set to be labeled with the resident’s name, date, time, and initials, but the container was observed without those identifiers and an RN confirmed the omission.
Unlabeled Enteral Nutrition and Water Bags Used for Tube Feedings
Penalty
Summary
The deficiency involves the facility’s failure to ensure enteral nutrition and water bags used for tube feeding were properly labeled and dated for two residents with active tube feeding orders. For one resident with diagnoses including type 2 diabetes mellitus, adult failure to thrive, mild protein-calorie malnutrition, and gastrostomy status, orders specified NPO status with Osmolite 1.2 at 100 mL/hr for 14 hours starting in the evening and water flushes at 40 mL/hr, along with enhanced barrier precautions related to enteral feedings. Surveyors observed two full bags, one containing enteral nutrition and one containing water, hanging at the bedside with lines attached but not yet connected to the resident. The formula was not in its original packaging but had been poured into an unlabeled plastic feeding bag. Neither the formula bag nor the water bag had any labeling to indicate the date or time of preparation, the type of formula, or the ordered rate. An LPN then entered the room, flushed the gastrostomy tube, connected the unlabeled bags to the resident, and started the feeding pump without adding any labels, and then left the room while the feeding was running, confirming in interview that both bags should have been labeled with date and time and acknowledging they were not. For a second resident with diagnoses including hemiplegia and hemiparesis following stroke, dysphagia following stroke, unspecified protein-calorie malnutrition, and gastrostomy, physician orders included continuous Glucerna 1.5 at 55 mL/hr with 50 cc water flushes every hour. The record also contained an order to change the tube feeding bag and tubing every night shift and to label new bags and bottles, including water, with name, date, time, and amount per hour. Surveyors observed at the bedside that the water bag hung next to the enteral nutrition bag was actively running to flush the tube feeding line but was not labeled with the date and time of preparation, although the enteral nutrition bag was labeled. In interview, an RN verified that the water bag was unlabeled, stated that water is usually prepared at the same time as the formula, and acknowledged that each individual bag should be labeled with date and time of preparation. These observations showed that the facility did not follow its own orders and labeling requirements for tube feeding products and water for both residents.
Failure to Provide Ordered G-Tube Care and Dressing
Penalty
Summary
The deficiency involves the facility’s failure to provide gastrostomy tube (G-tube) care and maintenance as ordered for a resident who was fully dependent on tube feeding. The resident had multiple diagnoses including dementia, acute respiratory failure, Type II diabetes mellitus with diabetic neuropathy, dysphagia, history of aspiration pneumonia, a G-tube, and hypertension, and was documented on the MDS as being in a persistent vegetative state, severely cognitively impaired, unable to make needs known, dependent for all ADLs, incontinent, and receiving all nutrition via feeding tube. The care plan identified potential for altered nutrition/hydration, with the resident ordered NPO and dependent on tube feeding and flushes, and included interventions such as administering medications as ordered, elevating the head of bed, and evaluating tube feed tolerance. Physician orders specified continuous tube feeding with Glucerna 1.2 via G-tube for up to 20 hours per day with scheduled water flushes, and a treatment order to cleanse the area around the G-tube with soap and water and apply a new sponge dressing daily and as needed. During an observation, an LPN entered the resident’s room and exposed the G-tube site, at which time no dressing (sponge) was in place despite the physician’s order for a daily dressing. The LPN cleansed a small amount of brown/red dried drainage from the G-tube insertion site and confirmed that a dressing should have been applied. In an interview, the DON stated that the facility did not have a policy or procedure in place regarding the provision of G-tube care and maintenance, and that the procedure was considered a standard of practice task. The facility also identified two additional residents with G-tubes, indicating that more than one resident required such care, but the cited deficiency specifically involved the failure to follow ordered G-tube care for this resident.
Wrong Tube Feeding Formula Administered
Penalty
Summary
The facility failed to ensure that a resident received enteral nutrition as ordered by the physician. Resident #22 had diagnoses including unspecified dementia, hemiplegia, gastrostomy status, dysphagia, and epilepsy, and the MDS indicated the resident was rarely or never understood, had a gastrostomy tube, and relied on enteral nutrition for 51% or more of fluid and nutrition needs. The current physician order directed Isosource HN at 80 ml per hour, but during observation the resident was receiving Fibersource HN at 80 ml per hour instead. The tube feeding bag was dated 03/10/26 at 4:00 A.M., and an LPN confirmed the resident was receiving the wrong formula and stated the bag had been hung by the previous shift.
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.
Tube Feeding Not Provided as Ordered
Penalty
Summary
The facility failed to ensure that Resident #23 received tube feeding nutrition as ordered by the physician. Resident #23 was admitted on 07/14/20 with diagnoses including epilepsy, dysphagia, type II diabetes mellitus, bipolar disorder, dementia, and gastrostomy status. The quarterly MDS dated 01/02/26 showed significantly impaired cognition, a feeding tube, and reliance on tube feeding for 51% or more of nutrition and fluid needs. The physician ordered Jevity 1.2 at 60 ml/hr for 21 hours per day, starting at 10:00 A.M. and stopping at 6:00 A.M. On 03/04/26 at 9:47 A.M., an LPN hung a one-liter bottle of Jevity 1.2 and it was running at 60 ml/hour. On 03/05/26 at 7:00 A.M., the resident's tube feeding bottle was observed empty and the pump was off, and the bottle was dated 03/04/26. The LPN confirmed it was the same bottle hung the previous morning and acknowledged the resident received only one liter instead of the ordered 1260 ml, stating a second bottle should have been hung to provide the full ordered amount.
Unlabeled Tube-Feeding Container
Penalty
Summary
The facility failed to label, date, or initial a resident’s supplemental tube-feeding container as ordered. Resident #70 was admitted with diagnoses including dysphagia, severe protein-calorie malnutrition, and hemiplegia and hemiparesis following cerebral infarction. The active physician orders for February 2026 directed staff to change the feeding administration set with each new bottle and to label the formula container, syringe, and administrative set with the resident’s name, date, time, and the nurse’s initials. During observation, the resident’s tube-feeding container was hung without being labeled, dated, or initialed, and an RN confirmed this during interview.
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