The Rate Was Right. The Run Time Wasn’t.

Behind the Deficiency
Real Survey Findings. Practical Lessons.

As a former state surveyor, the charts that concerned me most were not always the ones with missing information. Sometimes everything appeared to be there — an order, a specific rate, a Registered Dietitian assessment, and sound clinical reasoning.

The numbers looked right.

But the resident still wasn't receiving what those numbers said she should.

This case is a good example. The Registered Dietitian identified a nutrition problem, documented the clinical reasoning behind her recommendation, and recommended an appropriate increase in the resident's tube feeding. The physician's order reflected that recommendation.

The problem wasn't simply the rate.

It was whether the feeding was actually being delivered for the number of hours the calculation assumed — and whether anyone was verifying what the resident actually received.

This article is based on an actual, publicly available CMS-2567 deficiency report. The resident name used here is fictional, and selected details have been condensed for educational purposes.

What the Record Showed

Mrs. Alden had diagnoses that included dysphagia following a stroke and type 2 diabetes. She was NPO — nothing by mouth — and received all nutrition through a gastrostomy tube.

Her physician's order called for a 1.5-calorie-per-mL formula at 65 mL/hr across all three shifts, with a 300 mL water flush every four hours.

As written, the feeding was ordered to run continuously for 24 hours.

The 65 mL/hr rate had a clear clinical rationale behind it.

Several weeks earlier, the Registered Dietitian documented that Mrs. Alden had lost close to 12% of her body weight over the previous six months. She also had a pressure injury and increased protein and calorie needs.

Her feeding had previously been running at 55 mL/hr. The RD recommended increasing it to 65 mL/hr to address the continued weight loss and increased nutritional needs.

That is the kind of clinical reasoning we want to see: a specific problem, supporting evidence, and a targeted intervention.

But there was another question that mattered just as much:

Was the resident actually receiving the feeding the calculation assumed she was receiving?

The Deficiency

Surveyors observed Mrs. Alden's tube feeding pump on multiple occasions and compared what they saw with what should have been delivered at the ordered rate.

The numbers didn't match.

During one observation, approximately four and a half hours after a new bottle had been hung, substantially more formula remained than should have been present if the feeding had been running continuously at 65 mL/hr.

In other words, less formula had been delivered than the order called for.

The pump was also found displaying a "Hold error." A nurse had paused the feeding during care and had not restarted it. The alarm intended to alert staff could not be heard from the nearby medication cart.

Meanwhile, nursing staff were signing the medication administration record for the tube feeding and flushes at the end of each shift.

When surveyors asked how staff knew the resident had actually received the ordered feeding, staff explained that signing the order indicated the physician's order had been followed. It did not mean anyone had verified the actual amount delivered.

F693 — Tube Feeding Management — was cited because the facility failed to ensure the ordered enteral feeding was being monitored and delivered as prescribed.

The Nutrition Issue Underneath

This is where the case becomes more than a pump-management problem.

A tube feeding prescription is not just an hourly rate. Rate and run time work together to determine how much nutrition the resident actually receives.

At 65 mL/hr for 24 hours, the order represents 1,560 mL of formula per day.

If the feeding doesn't run for 24 hours, the resident doesn't receive 1,560 mL.

In long-term care, predictable interruptions are part of the resident's day. Feedings may need to be stopped for bathing, ADLs, medications, therapy, appointments, mobility, treatments, or other care.

That doesn't mean those interruptions should simply be absorbed into a 24-hour order. If the feeding is ordered continuously over 24 hours, interruptions reduce the amount actually delivered.

In my own long-term care practice, I generally calculate continuous tube feedings over no more than 20 to 22 hours. This intentionally allows planned downtime while giving me a realistic run time on which to calculate the hourly rate needed to provide the resident's intended daily nutrition.

The exact schedule should always be individualized. The important point is that run time should be intentional.

That also means looking at the resident's full schedule. Hemodialysis, recurring treatments, appointments, or other predictable time away from the pump can significantly reduce available feeding time.

Medication timing matters too. The RD should review the medication regimen and collaborate with nursing and pharmacy to identify any medications that require the feeding to be held before or after administration. Those planned holds need to be considered when determining a realistic run time.

A feeding calculated over 22 hours is not truly a 22-hour feeding if hemodialysis, medication holds, or other predictable interruptions routinely reduce actual delivery to considerably fewer hours.

In this case, staff described the rate as being approximately 10 mL/hr higher than the resident's calculated need in an effort to compensate for interruptions. But without a defined run time and intended daily volume, an informal cushion still leaves an unanswered question: was the resident actually receiving enough?

And when the pump was found on hold for an unknown amount of time, that question became even more important.

This is the distinction I want dietitians to take from this case:

Did I calculate what this resident needs — or did I calculate what this resident will actually receive?

In long-term care, those are not automatically the same thing.

Look Beyond the Order

There is another important lesson here for dietitians.

The surveyors didn't identify the problem by reviewing the order alone.

They looked at the feeding.

That same type of bedside check should be part of the RD's routine observation of a resident receiving enteral nutrition.

Look at the formula. Is the correct product hanging? Is it labeled appropriately?

Look at the pump. Is it actually running? Does the rate displayed match the current order?

And look at how much has infused.

If a feeding has been hanging for several hours at a known rate, the amount infused should reasonably correspond with what should have been delivered during that time. If it doesn't, that discrepancy deserves investigation.

This isn't about the dietitian taking over nursing responsibilities. It is about verifying that the nutrition intervention is actually being delivered as prescribed.

The RD should not wait for continued weight loss, poor wound healing, or another adverse outcome before looking.

A signed MAR and a correct nutrition calculation tell us what was supposed to happen.

The bedside helps tell us whether it actually did.

This Case, and the Rest of This Series

The first article in this series looked at a defined trigger that existed but was never acted on. The second looked at a trigger so vague it was never activated in the first place. This case is a third version of the same underlying problem: an intervention that exists on paper without a reliable path to being carried out as intended.

What makes this one harder to catch is that nothing about the order looked incomplete. It had a specific rate, a specific formula, and a clear rationale. A precise number can create a sense that the clinical question has already been answered — sometimes it has, and sometimes the next step is to leave the chart, look at the pump, and find out.

Where the R.I.S.E. Method™ Fits

Recognize means noticing when the expected outcome isn't occurring — or when what you see at the bedside doesn't match what the record says should be happening.

Investigate means looking beyond the ordered rate to actual delivery: formula, rate, run time, interruptions, labeling, volume infused, medication holds, and recurring treatments that affect the feeding schedule.

Strategize means developing an individualized feeding prescription that accounts for realistic planned downtime while still meeting the resident's nutrition and hydration needs.

Evaluate means confirming that the prescribed feeding is actually being delivered and that the resident is responding as expected.

This case is a good example of why the R.I.S.E. Method™ begins with investigation rather than assumption. A tube feeding order can look appropriate on paper while the bedside reveals an entirely different story.

What Dietitians Can Take From This Case

A correct tube feeding calculation is only the beginning. The prescribed run time needs to reflect how the feeding is realistically intended to be delivered.

When determining run time, consider predictable downtime — including bathing, ADLs, therapy, appointments, hemodialysis or other recurring treatments, and medication-related feeding holds.

During resident observations, look at the actual feeding. Verify the formula, labeling, pump status, rate, and approximate amount infused against what should have been delivered.

If the resident isn't responding as expected, investigate actual delivery before automatically increasing the rate or recalculating needs.

And remember:

Good clinical reasoning only helps the resident when the intervention is actually delivered as intended.

FAQs

If the RD's clinical reasoning was correct, how did this still become a deficiency?

The deficiency centered on the facility's failure to ensure the ordered feeding was being monitored and delivered as prescribed.

The RD appropriately identified the resident's weight loss and increased nutrition needs. But the effectiveness of that intervention depended on the resident actually receiving the feeding that had been calculated.

How should an RD determine an appropriate tube feeding run time?

The feeding schedule should be individualized to the resident. In my own LTC practice, I generally use no more than a 20- to 22-hour run time so planned downtime is already accounted for.

Consider the resident's entire schedule, not just estimated nutrition needs. Routine care, ADLs, therapy, appointments, hemodialysis or other recurring treatments, and medication-related feeding holds may all affect how many hours the feeding can realistically run.

Review the medication regimen and collaborate with pharmacy and nursing when medication timing may affect enteral feeding.

The important principle is not a specific number of hours — it is that the prescribed rate, duration, and intended daily volume work together and reflect a realistic plan for that resident.

What should an RD check during a tube feeding observation?

Look beyond the chart. Verify that the correct formula is hanging, the feeding is appropriately labeled, the pump is running at the ordered rate, and the amount infused reasonably matches what should have been delivered based on the rate and elapsed time.

If something doesn't add up, investigate.

What should trigger a deeper review of tube feeding delivery?

Don't wait for a poor outcome to check delivery. Routine observation should be part of evaluating a tube-fed resident.

But continued weight loss, poor wound healing, inadequate hydration, or another unexpected outcome makes that investigation especially important. Before assuming the resident needs more nutrition, determine whether they are consistently receiving what has already been prescribed.