Failure to Properly Label Enteral Feeding Bags
Penalty
Summary
The facility failed to ensure that residents with enteral feeding tubes received appropriate treatment and services to prevent potential complications. This deficiency was identified for four residents who were observed with enteral feeding bags and water flush bags that were not properly labeled with dates. The facility's policy requires that enteral nutrition labels be checked against orders before administration, including the resident's name, ID, room number, type of formula, date, and time the formula was prepared, and rate of administration. Resident R40, who was admitted with diagnoses including difficulty walking, cancer, and hyperlipidemia, had an enteral feeding bag dated correctly, but the water flush bag lacked a date. Similarly, Resident R53, with diagnoses of quadriplegia, chronic pulmonary disease, and anxiety disorder, had a feeding bag dated, but the water flush bag was not labeled. Resident R70, diagnosed with cancer, depression, and peripheral vascular disease, had neither the feeding bag nor the water flush bag dated. Lastly, Resident R103, with coronary artery disease, heart failure, and hypertension, also had both bags without dates. Interviews with registered nurses confirmed the absence of dates on the water flush bags and, in some cases, the feeding bags. The Director of Nursing acknowledged the facility's failure to ensure proper labeling, which is crucial to prevent potential complications associated with enteral feeding. This oversight affected four out of five residents reviewed, indicating a systemic issue in adhering to the facility's enteral feeding management policy.
Plan Of Correction
Residents RO, R52, R70, and R103 tube feeds/water flushes/tubing were dated at the time of survey. A whole house sweep was conducted to ensure all tube feeds/water flush/tubing was dated. The DON or designee will educate all Licensed Nurses on labeling and dating all components of the tube feed system. The DON or designee will audit all tube feeds daily x3, and five tube feeds weekly for proper labeling and dating of tube feed systems. All results to be reviewed through QAPI for further recommendation.