Failure to Ensure Proper Enteral Feeding Management
Penalty
Summary
The facility failed to ensure that residents with an enteral feeding tube received appropriate treatment and services to prevent potential complications. This deficiency was identified for one of three residents, specifically Resident R379. The resident, who was admitted to the facility with diagnoses including high blood pressure, cerebral infarction, and dysphagia, was receiving enteral nutrition through a feeding tube. The physician's order specified that Osmolite 1.2 should be administered continuously over 24 hours, with the tube being flushed with 30 ml of warm water every hour. During an observation, it was noted that Resident R379's enteral feeding and water flush bag did not have a date written on them, which is a critical step in ensuring the safety and efficacy of the feeding process. This oversight was confirmed by an LPN and later by the Director of Nursing, who acknowledged the facility's failure to provide appropriate treatment and services to prevent potential complications for the resident. The lack of proper labeling could lead to issues such as contamination or incorrect administration of the feeding solution.
Plan Of Correction
1. Feeding bottle and flush bag for R379 was changed and labeled with hang date and time. 2. A house audit was done of residents with tube feeding to ensure all feeding bottles and flush bags were dated and timed. No additional issues identified. 3. Director of nursing or designee will in-service licensed nursing staff to ensure tube feeding and supplies are dated and timed upon hanging. 4. Director of nursing or designee will audit 3 residents with tube feeding weekly for 2 weeks, then 2 residents weekly for 2 weeks, then 3 residents monthly for 2 months to ensure date and time are present on feeding bottle and flush bags. Audit findings will be shared with QAPI committee.