Deficiencies in Tube Feeding Management and Documentation
Penalty
Summary
The facility failed to ensure proper management of tube feeding services for two residents, leading to deficiencies in documentation and labeling. For one resident, the flow sheet lacked documentation of water flushes and tube feeding administration on multiple dates. During an observation, the tube feeding machine was found to be off, and the feeding bag lacked essential information such as the product name, time, and rate of administration. The Licensed Practical Nurse (LPN) on duty admitted to transferring the product from its original packaging due to a tubing issue, which was not completed by the previous nurse. For another resident, the tube feeding setup was observed with an empty bottle that lacked documentation of the rate, and the bottle was not labeled with the time it was hung. A subsequent review with the Director of Nursing (DON) revealed a full bottle with missing time and rate information. The facility's policy on enteral tube management, which includes responsibilities such as assessing tube placement and administering feedings, was not adhered to, as evidenced by the lack of proper labeling and documentation.
Plan Of Correction
A new was immediately hung, verified, dated, and timed by the licensed Nurse for residents #1 and #9. The Director of Nursing immediately completed quality review for residents #1 and #9 to ensure is being provided in accordance with the MD order accurate product, hang time, rate, and date is clearly displayed. Complete quality review of current residents within the facility receiving feeding to ensure accuracy of following MD order for feeding as follows; accurate product, hang time, rate, and date is clearly displayed on containers. Revision of current policy and procedure for feed. The Director of Nursing or designee will re-educate the current licensed nurses on the tube management policy and procedure and the nurse's responsibilities when caring for a resident with an. The Director of Nursing or designee will complete quality reviews daily for 2 weeks, weekly for 4 weeks, then monthly for 2 months. Findings from the quality review audits will be reviewed and discussed by the Quality Assurance Performance Improvement (QAPI) Committee monthly for 3 months. Non-compliance will be reviewed by the QAPI committee with direct changes to the plan as deemed necessary to ensure ongoing and sustained compliance.