NATCHITOCHES, LA - Federal inspectors cited Natchitoches Community Care Center for serious violations involving inadequate nutrition delivery to a tube-fed resident and multiple infection control failures that potentially exposed all 108 residents to preventable health risks.
Critical Nutrition Management Failure Puts Resident at Risk
The most severe violation documented at Natchitoches Community Care Center involved a systematic failure in tube feeding administration that left a resident receiving only 55% of their prescribed nutrition for over 10 days. Federal surveyors found that a clinical coordinator misread dietary recommendations and entered an incorrect feeding rate into the resident's medical orders, creating what inspectors classified as "immediate jeopardy" to the resident's health.
The incident began when a registered dietitian assessed the resident on July 4, 2024, and recommended increasing their tube feeding from 900 calories daily to 1,200 calories to address ongoing weight loss. The dietitian specifically recommended continuous feeding at 45 ml per hour of Diabetisource AC nutritional formula. However, when the facility's clinical coordinator communicated this recommendation to the nurse practitioner on July 5, she misread the rate and entered an order for only 25 ml per hour.
This error meant the resident received approximately 600 calories daily instead of the prescribed 1,080 calories - a deficit that continued undetected from July 5 through July 15, 2024. During an inspection observation, the resident communicated through typing on her phone: "I'm hungry, I'm losing weight" and "It felt like they were starving me and there was nothing I could do. I asked the nurse practitioner if I'm gonna die."
Understanding the Medical Impact of Inadequate Tube Feeding
Tube feeding provides essential nutrition for residents who cannot safely consume food orally due to swallowing difficulties, neurological conditions, or other medical complications. The prescribed feeding rate is carefully calculated based on the individual's nutritional needs, medical condition, and metabolic requirements.
When tube feeding rates are insufficient, residents face multiple serious health consequences. Inadequate caloric intake leads to protein-energy malnutrition, which compromises immune function and increases infection risk. Weight loss in medically fragile residents can accelerate muscle wasting, delay wound healing, and increase the risk of pressure ulcers. For diabetic residents receiving specialized formulas like Diabetisource AC, inadequate nutrition can also disrupt blood sugar management.
The 10-day period of reduced nutrition delivery represented a significant medical concern. Healthcare standards require that tube feeding orders be precisely followed, as these residents depend entirely on artificial nutrition for survival. The caloric deficit of approximately 4,800 calories over the 10-day period could contribute to measurable weight loss and nutritional decline.
Systemic Communication Failures in Dietary Management
The investigation revealed that Natchitoches Community Care Center lacked standardized procedures for communicating and implementing dietary recommendations. The Director of Nursing confirmed that "there was not one standard facility process for obtaining, communicating and carrying out dietary recommendations." Each unit's clinical coordinator was responsible for obtaining and implementing dietary recommendations for their residents, creating inconsistent practices across the facility.
The facility's Assistant Director of Nursing, who supervised the clinical coordinator responsible for the error, acknowledged that she amended the resident's order on July 9 but failed to review the infusion rate or compare it to the original dietary recommendations. This oversight allowed the incorrect feeding rate to continue for an additional six days after the facility had an opportunity to identify and correct the error.
Federal regulations require nursing homes to maintain accurate medication and treatment orders, with proper verification systems to prevent errors that could harm residents. The facility's admission that it lacked systematic verification processes for dietary recommendations represents a fundamental breakdown in quality assurance protocols.
Infection Control Violations Expose Residents to Disease Risk
Inspectors also documented significant infection control failures that created unnecessary exposure risks for residents. During meal service observation, surveyors witnessed a certified nursing assistant providing hands-on feeding assistance to two residents while seated between them, without performing hand hygiene between contacts. This practice violates basic infection control principles and creates a direct pathway for transmitting pathogens between residents.
Hand hygiene represents the single most effective intervention for preventing healthcare-associated infections. When staff assist multiple residents with eating without proper hand hygiene, they can transfer bacteria, viruses, and other microorganisms between individuals. This risk is particularly concerning for nursing home residents, who often have compromised immune systems and multiple chronic conditions that increase their susceptibility to infections.
Enhanced Barrier Precaution Violations During Wound Care
A second infection control violation involved improper use of personal protective equipment during wound care for a resident requiring enhanced barrier precautions. Inspectors observed a treatment nurse leaving the resident's room while still wearing contaminated gown and gloves to retrieve supplies from a cart in the hallway. This practice directly contradicts infection control protocols designed to prevent the spread of multidrug-resistant organisms and other pathogens.
Enhanced barrier precautions are implemented for residents who carry specific infectious organisms or have conditions requiring additional protection measures. The protective equipment worn during care must be removed before leaving the resident's room to prevent contaminating clean areas and equipment. When staff violate these protocols, they risk spreading dangerous pathogens throughout the facility.
Medical Standards and Best Practices
Professional standards require nursing homes to implement comprehensive infection prevention and control programs that address all aspects of resident care. The Centers for Disease Control and Prevention provides specific guidelines for hand hygiene in healthcare settings, recommending alcohol-based hand sanitizer or handwashing with soap and water before and after each resident contact.
For nutrition management, healthcare facilities must establish systems that ensure accurate communication and implementation of dietary orders. Best practices include verification protocols where multiple staff members confirm critical information, electronic systems that flag potential errors, and regular monitoring to ensure prescribed treatments are delivered as ordered.
Additional Issues Identified
Federal surveyors also documented that the facility failed to maintain current copies of all medical orders in residents' clinical records, as required by their own policies. The inspection revealed gaps in the facility's order communication systems, particularly regarding how verbal, telephone, and written prescriptions are documented and verified.
The violations occurred despite the facility having written policies addressing medication orders and dietitian responsibilities, indicating a disconnect between established procedures and actual practice implementation.
The survey findings highlight systemic quality assurance failures that extended beyond individual staff errors to encompass the facility's overall approach to resident safety and care coordination. Federal regulations require nursing homes to maintain comprehensive systems that protect resident health and prevent avoidable complications through proper care delivery and infection control measures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Natchitoches Community Care Center from 2024-07-18 including all violations, facility responses, and corrective action plans.
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