Improper Labeling of Tube Feeding Bags
Penalty
Summary
The facility failed to ensure proper labeling of tube feeding bags for a resident, identified as Resident R79, who was receiving enteral nutrition. The resident, admitted to the facility in September 2023, had significant medical conditions including anoxic brain damage and dysphagia, necessitating the use of a feeding tube. According to the physician's orders, the resident was to receive Peptamen AF formula in 375 mL boluses four times daily, with specific instructions to change and label the feeding bag and administration set daily with the resident's name, date, time, and initials of the person preparing the feeding. During an observation on January 12, 2025, it was noted that the tube feeding bag in use for Resident R79 was only labeled with the date, lacking the resident's name, formula, infusion rate, and the preparer's initials. Employee E8, a licensed nurse, confirmed that the bag was not properly labeled according to the facility's policy and the physician's orders. This oversight in labeling could potentially lead to errors in the administration of the resident's nutritional support.
Plan Of Correction
Resident R79's tube feed label was updated. A house-wide audit of residents with tube feedings was completed to ensure that tube feedings were labeled properly. Licensed staff will be in-serviced to ensure that tube feedings are properly labeled. The Director of Nursing/Designee will conduct a random audit of five residents to ensure that tube feedings are properly labeled. This audit will be completed weekly for four weeks and then monthly for three months. This plan of correction will be monitored at the monthly Quality Assurance Performance Improvement meeting until such time consistent substantial compliance has been met.