Inadequate Sanitation of Tube Feeding Equipment
Penalty
Summary
The facility failed to maintain a tube feeding pole in a sanitary manner for a resident who was dependent on enteral feeding due to severe cognitive impairment and medical conditions including Hemiplegia, Hemiparesis, Dysphagia, and Diabetes. Observations revealed that the tube feeding pole and base had a thick layer of brown dried tube feed stuck to it, and a bag of Isosource 1.5 cal was missing the resident's name, date, time, or order. Additionally, used gloves were found on the floor, and a pool of wet fluid was observed on the floor. The Infection Control Preventionist stated that the expectation was for the pole to be cleaned when soiled, but this was not adhered to, as evidenced by multiple observations of the soiled pole over several days. The facility's policy on cleaning and disinfection of resident-care equipment was not followed, as the tube feeding equipment was not stored in the soiled utility room as required.
Plan Of Correction
Element 1 It is the practice of the facility to ensure appropriate infection control practices are used for equipment cleaning. The Nursing and Housekeeping staff were educated on cleaning of the tube feed pole and spills on the floor. Element 2 Residents that have a peg tube pole in the facility have the potential to be affected by this cited practice. Residents' rooms with a tube feeding pole were audited and cleaned. Element 3 The Interdisciplinary Team reviewed the policy and procedure titled: Cleaning and Disinfection of Resident-Care Equipment was reviewed and deemed the policies to be appropriate. Nursing and Housekeeping will continue to be educated on this policy. Element 4 Environmental Manager/designee will randomly audit on residents with tube feeding poles to ensure there are no spills on the floor or pole itself for 4 weeks and then monthly x 3 months. Results of audits will be taken through QA for further review and recommendations. The Administrator will be responsible for sustaining compliance.