Inadequate Management of Tube Feeding Services
Penalty
Summary
The facility failed to ensure adequate management of services for two tube-fed residents, as evidenced by inaccurate dating and non-labeling of feeding products. For one resident, the care plan required specific feeding and water flushes, but the flow records lacked documentation of these services being performed at the prescribed times. Additionally, the feeding setup was observed to be incomplete, with the machine turned off and the feeding bag lacking essential information such as the product name, time, and rate of administration. During a review with the Director of Nursing, it was noted that there were blanks in the flow records, and the DON was unable to explain why staff had not initialed the records. An observation of the resident's feeding setup revealed that the bag was filled to the 1000 mark but did not have the necessary labeling, which is crucial for ensuring proper administration and tracking of nutritional intake.
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.