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Based on document review and interview, the facility failed to ensure one of ten patients had dietary needs fulfilled as ordered.

Findings include:

1. Policy #I-B.27, Behavior of Employees, issued 5/2015, which indicated: Employees are expected to perform assigned tasks efficiently and in accordance with established standards.

2. Nutrition Risk Data Collection and assessment on 5/14/2018 at 1200 hours, by staff member #10, Clinical Dietitian (RD), indicated patient #2 is at high risk for nutritional deficiencies due to recent weight loss, tube feedings (has gastroscopy (g)-tube and jejunostomy (peg) or (j)-tube), dysphagia, and low albumin.

3. Review of Ancillary Orders for patient #2 indicated feeding orders were:
A. Entered by staff #10, RD, (following dietary assessment): and co-signed by QMP #2 on 5/14/2018 at 1505 hours: Tube feeding and j-tube Jevity 1.5 or Isosource 1.5 continuous feeding via j-tube by pump at 93 ml per hour, times 14 hours from 7 pm until 9 am, or until 1302 ml infused. Tube feeding: J-tube and water flush every two hours via j-tube.

4. MAR indicated this was not started until 5/15/2018 at 1930 hours. Patient did not receive tube feeding as ordered on the evening of 5/14/2018.