Medilodge of Farmington: Feeding Tube Overdose - MI
The patient, identified as R905, was supposed to receive 720ml of Glucerna formula over 16 hours through a gastrostomy tube. Instead, staff delivered 1,191ml before a nurse discovered the error on July 31.
"Resident abdominal area was hard and distended," wrote the nurse who found R905 in distress. The nurse immediately pulled 1,000cc of residual formula from the patient's stomach and called for emergency abdominal X-rays.
The overdose stemmed from a transcription error made during the patient's admission. The original hospice physician had ordered Glucerna 1.2 at 40ml per hour for 16 hours. But facility staff transcribed this as 45ml per hour, increasing both the hourly rate and total volume by 25 percent.
R905 had been admitted with dysphagia and gastrostomy status, conditions requiring precise nutrition management. The patient was discharged August 3, just days after the feeding incident.
Nurse A, who discovered the overfeeding during morning rounds, told inspectors the facility's enteral pumps would continue running indefinitely unless programmed with stop times. The nurse reported finding R905 had received "over what they were supposed to have" and immediately contacted medical providers.
The attending nurse practitioner ordered all tube feeding stopped and requested emergency abdominal imaging. The Director of Nursing was notified of the error along with the incoming shift nurse.
Federal inspectors reviewed the incident following a complaint filed September 2 with the State Agency. The complaint specifically alleged R905 "was fed an incorrect amount of enteral formula."
When questioned September 3, the Director of Nursing acknowledged awareness of the error and said staff had received additional training "on ensuring enteral orders are administered appropriately."
The facility's own feeding tube policy requires that "administration of enteral nutrition is consistent with and follows the practitioner's orders." The policy also mandates feeding tubes be "maintained in accordance with current clinical standards of practice, with interventions to prevent complications to the extent possible."
Nurse A explained to inspectors that the overfeeding caused visible abdominal distension in R905. The nurse emphasized reporting the error immediately to both medical providers and nursing leadership.
The 65 percent overdose represented a significant volume error. At the prescribed 40ml hourly rate, R905 should have received exactly 640ml over 16 hours. The transcribed 45ml rate called for 720ml. But the actual delivery of 1,191ml exceeded even the incorrect order by 471ml.
Federal regulations require nursing homes ensure feeding tubes are used appropriately and that residents receive proper care when tube feeding is medically necessary. The regulations specifically mandate accurate administration according to physician orders.
R905's case illustrates how transcription errors can cascade into dangerous overfeeding. The initial 5ml per hour increase seemed minor but resulted in receiving nearly twice the intended nutrition volume.
The patient's hospice status made accurate feeding particularly critical, as comfort care requires precise symptom management. Abdominal distension and the need for residual removal represented exactly the type of complications hospice care seeks to prevent.
Inspectors found the facility failed to ensure enteral feeding orders were "accurately transcribed upon admission and administered correctly." The violation affected R905 among two residents reviewed for enteral feeding practices.
The emergency intervention required stopping all nutrition and imaging to assess potential complications from the massive overfeeding. The hard, distended abdomen indicated R905's digestive system was overwhelmed by the excess formula volume.
Staff training following the incident focused on proper order transcription and administration procedures. But for R905, the damage was already done - a hospice patient experienced unnecessary distress due to preventable medication errors during what should have been comfort-focused care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Medilodge of Farmington from 2025-09-04 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 16, 2026 · Our methodology
Medilodge of Farmington in Farmington, MI was cited for violations during a health inspection on September 4, 2025.
The patient, identified as R905, was supposed to receive 720ml of Glucerna formula over 16 hours through a gastrostomy tube.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at Medilodge of Farmington?
- The patient, identified as R905, was supposed to receive 720ml of Glucerna formula over 16 hours through a gastrostomy tube.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in Farmington, MI, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Medilodge of Farmington or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 235293.
- Has this facility had violations before?
- To check Medilodge of Farmington's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.