Natchitoches Community Care: Tube Feeding Harm LA
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.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
NATCHITOCHES COMMUNITY CARE CENTER in NATCHITOCHES, LA was cited for violations during a health inspection on July 18, 2024.
The dietitian specifically recommended continuous feeding at 45 ml per hour of Diabetisource AC nutritional formula.
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.