Failure to Document Gastric Residual Volumes for Enteral Feeding
Penalty
Summary
The facility failed to adhere to its policy regarding the documentation of gastric residual volumes (GRV) for a resident with an enteral feeding tube. According to the facility's policy, staff were required to check and document the GRV every shift to assess the resident's tolerance to enteral feeding and minimize the risk of aspiration. If the GRV exceeded 250 mL, the physician was to be notified, and the resident was to be assessed for feeding intolerance. However, a review of the clinical records for Resident 70, who was cognitively impaired and had an enteral feeding tube, revealed that there was no documented evidence of GRV checks from January 1 to January 17, 2025. Physician's orders for Resident 70 specified that the GRV should be checked every shift, and specific actions were to be taken if the GRV exceeded certain thresholds. Despite these orders, the facility did not document the GRV checks as required. An interview with the Director of Nursing confirmed the absence of documentation for the GRV checks in the resident's clinical record, indicating a failure to comply with the facility's policy and the physician's orders.
Plan Of Correction
1. Medical Director was immediately notified of staff not documenting residuals. Electronic Medication Administration Record updated to reflect spot for documentation of residual amount. Resident 70 suffered no ill effects. 2. Audit completed for all residents receiving feedings completed to ensure that residual is being documented. 3. Director of nursing/designee completed Education with licensed nursing staff on the facility policy for checking residual every shift. 4. Director of nursing or designee will audit Electronic Medication Administration Record for all residents receiving feedings 2 x week for 4 weeks and monthly for 2 months to ensure residual is being documented. 5. Date of compliance 3/5/2025