Failure to Ensure Appropriate Enteral Feeding Tube Care
Penalty
Summary
The facility failed to ensure that a resident with an enteral feeding tube received appropriate treatment and services to prevent potential complications. The facility's policy on Enteral Nutrition, dated 1/2/25, mandates that adequate nutritional support through enteral nutrition is provided to residents as ordered, based on a comprehensive nutritional assessment and consistent with current standards of practice. However, during an observation on 1/7/25, it was noted that Resident R14's enteral feeding and water flush bag were hanging undated on a pole at the bedside. This was confirmed by Registered Nurse Employee E6, indicating a lapse in the facility's adherence to its policy and the provision of appropriate care. Resident R14, who was admitted to the facility with diagnoses including cerebral infarction, dependence on renal dialysis, and aphasia, had a Minimum Data Set indicating the presence of a feeding tube. The current physician orders specified a continuous enteral feed order with Nepro at 85 ml/hr for 19 hours, along with a 60 ml water flush every 4 hours. The failure to date the feeding and water flush bags could lead to potential complications, as the facility did not ensure the resident received the necessary treatment and services as per the physician's orders and facility policy.
Plan Of Correction
The tube feeding and water flush bag for resident R14 have been dated. RNs and LPNs will be educated by the Director of Nursing, In-Service director or designee on the importance of placing the date hung on both the tube feeding and water flush bag. An audit of all residents having a tube feeding will be conducted weekly for three weeks by the Director of Nursing or designee. Then the audit will be conducted biweekly of all residents receiving a tube feeding. Any deficient practice will be immediately corrected. All data will be forwarded to the QAPI committee and the need for additional monitoring will be determined by the committee.