Federal inspectors found the error on September 10 during a complaint investigation. Resident 72, who has cancer of the mouth, esophagus and other unspecified sites, was connected to a feeding pump delivering the incorrect supplement at 9:45 AM.
The physician's order from August 20 was clear: administer Jevity 1.5 at 125 milliliters per hour for 16 hours daily, providing 2,000 milliliters total. Instead, staff had been giving Glucerna 1.5 at the same rate and duration.
Unit Manager 1 and LPN 2 confirmed at 10:00 AM that the resident was indeed receiving Glucerna 1.5. Nine minutes later, the unit manager acknowledged the mistake.
"Resident 72 had been given the incorrect nutritional supplement and that the physician's order had not been followed," the manager told inspectors.
The resident was admitted to the facility in late August with multiple cancer diagnoses requiring tube feeding. Their care plan, initiated on August 24, documented the feeding tube orders.
Timber Springs' own policy, revised in July, directed staff to confirm physician orders before administering anything through feeding tubes. The policy specifically required verification to prevent exactly this type of error.
The two nutritional supplements serve different medical purposes. Jevity 1.5 is a standard tube feeding formula for patients who need complete nutrition. Glucerna 1.5 is designed specifically for diabetic patients to help manage blood sugar levels.
For a cancer patient already dealing with mouth and esophageal tumors, receiving the wrong nutritional support creates additional risks. The inspection report noted this failure "created the potential for poor nutrition when the incorrect nutritional supplement was administered."
The error raises questions about how long the resident received the wrong formula before inspectors discovered it. The physician order dated August 20, but the facility's records don't indicate when staff began administering Glucerna instead of Jevity.
No staff member caught the discrepancy during routine checks. The mistake only came to light when federal inspectors observed the feeding process firsthand and compared what they saw to the written orders.
This represents a fundamental breakdown in medication administration safety. Feeding tube nutrition isn't optional for residents who can't eat normally. Getting the wrong formula can compromise recovery, especially for someone fighting multiple cancers.
The facility's July policy revision suggests recent awareness of feeding tube administration problems. Yet staff still failed to follow the basic requirement of checking orders against what they were actually giving the resident.
Unit managers and licensed practical nurses are specifically trained to verify orders before administration. Both the unit manager and LPN confirmed they were giving Glucerna, indicating they knew what supplement was being administered but hadn't checked it against the physician's directive.
Federal inspectors classified this as a minimal harm violation affecting few residents. But for Resident 72, the impact was direct and ongoing until the error was discovered.
The resident's cancer diagnoses make proper nutrition critical for treatment tolerance and recovery. Mouth and esophageal cancers often compromise normal eating, making tube feeding the primary source of nutrition and calories.
Staff had been following their own incorrect routine for weeks, potentially undermining the resident's nutritional status during cancer treatment. The systematic nature of the error suggests inadequate oversight of feeding tube protocols.
The inspection occurred during a complaint investigation, though the report doesn't specify whether the feeding tube error was the subject of the original complaint or discovered during the broader review.
Resident 72 continues to require tube feeding for their cancer treatment. Whether they suffered measurable nutritional deficits from receiving diabetic formula instead of standard nutrition remains undocumented in the inspection findings.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Timber Springs Transitional Care from 2025-09-12 including all violations, facility responses, and corrective action plans.
Additional Resources
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