Deficiencies in Enteral Feeding Management
Penalty
Summary
The facility failed to properly monitor and manage the enteral feeding of two residents, leading to deficiencies in their care. Resident R31, who has a history of high blood pressure, diabetes, and aphasia, was observed with an enteral feeding setup that lacked proper labeling. The enteral feeding bag, water flush bag, and syringe were not dated, which is against the facility's policy that requires these items to be dated to ensure proper usage and prevent complications. Similarly, Resident R95, diagnosed with atrial fibrillation, parkinsonism, and difficulty walking, was found with an expired enteral feeding product and an undated water flush bag. The wrong feeding product, Fibersource HN, was hanging at the bedside, which was confirmed by LPN Employee E9 to be expired. These oversights in labeling and product management indicate a failure to adhere to the facility's policies on enteral feeding management, potentially compromising the residents' nutritional care and safety.
Plan Of Correction
R31's tubing was dated and labeled. R95's tubing was dated, labeled, and the correct tube feeding was hung. To identify other residents that have the potential to be affected, the Director of Nursing (DON)/designee reviewed current residents with enteral tube feedings to ensure proper enteral feeding is hanging, enteral feeding bag and water flush bag are dated, and syringe is dated. Corrections made as needed. To prevent this from recurring, the Regional Director of Clinical Services (RDCS)/designee educated licensed staff on the enteral tube feeding policy (appropriate enteral feed and dating). To monitor and maintain ongoing compliance, the DON/designee will audit enteral tube feedings for correct tube feed, correct labeling, and expiration 2x a week x4 then monthly x 2. Negative findings will be addressed. Ad Hoc education will be provided as needed. The results of the audits will be forwarded to the facility Quality Assurance Performance Improvement (QAPI) committee for further review and recommendations.