The patient, identified as Resident #1, was admitted on September 10th with orders for Osmolite 1.5 cal nutritional formula to be delivered through their gastrostomy tube four times daily. But on September 11th, medication aide records show only two feedings were actually given.
The confusion started with conflicting orders in the facility's electronic system. The original admission order scheduled tube feedings at 10:00 AM, 2:00 PM, 6:00 PM, and 10:00 PM. But at 3:37 PM on September 11th, a new order changed those times to 12:00 AM, 6:00 AM, 12:00 PM, and 6:00 PM.
Medication Aide #1 worked a double shift that day and signed off on giving feedings at 10:00 AM under the original schedule and 6:00 PM under the revised schedule. The medication administration record shows blank spaces where the 2:00 PM feeding should have been documented, and X marks by the midnight, 6:00 AM, and noon times on the new schedule.
When interviewed by inspectors on October 17th, the medication aide said she only called for nursing assistance twice that day to administer tube feedings. She recalled the computer system flagging only two enteral feedings as due during her shift.
The missed feedings created a dangerous gap in nutrition for a patient whose diabetes required consistent caloric intake. Each 300ml feeding of Osmolite 1.5 provides 450 calories, meaning the patient received only 900 calories instead of the prescribed 1,800 calories that day.
Nurse #6, who worked the day shift on September 11th, told inspectors she couldn't find the admission orders or hospital discharge summary when she looked for them during her shift. She said it appeared the orders hadn't been properly confirmed in the electronic system, though she did see instructions to flush the patient's gastrostomy tube and completed that task.
The nurse administered no enteral feedings to the resident during her shift.
Federal inspectors found the facility failed to ensure the patient received their prescribed nutrition therapy as ordered by their physician. The violation occurred during a critical transition period when the patient was adjusting to their new care environment and medical routine.
The inspection report notes that despite missing half their tube feedings on September 11th, the patient experienced no documented episodes of low blood sugar on either September 10th or 11th. However, the missed nutrition doses represented a significant deviation from the prescribed care plan for a diabetic patient who relied on tube feedings for proper nutrition.
The medication aide's interview revealed systemic problems with how the facility managed changing physician orders. She worked a 16-hour double shift but only recognized two feeding times as due, suggesting either inadequate training on the electronic medication system or poor communication about the revised feeding schedule.
The facility's medication administration record showed the confusion in real time. Two different feeding schedules appeared on the same day's documentation, with the aide signing off under both systems without apparent recognition that she was missing required doses.
Clayton Rehabilitation and Healthcare Center received a minimal harm citation for the violation, indicating inspectors determined the missed feedings created potential for harm but didn't cause serious injury. The facility serves patients requiring skilled nursing care and rehabilitation services in Johnston County.
The case highlights ongoing challenges nursing homes face when managing complex medication schedules during patient transitions. Electronic systems designed to prevent medication errors can sometimes create confusion when orders change rapidly, particularly during admission periods when multiple physicians may be adjusting care plans.
For Resident #1, the missed tube feedings meant going nearly 20 hours between some nutrition doses on a day when their body was already adjusting to a new care environment. The patient's diabetes made consistent nutrition timing particularly important for maintaining stable blood sugar levels.
The inspection found no evidence that nursing staff recognized the missed feedings in real time or took corrective action to ensure the patient received proper nutrition on subsequent days.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Clayton Rehabilitation and Healthcare Center from 2025-10-30 including all violations, facility responses, and corrective action plans.
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