Deficiency in Enteral Feeding Management
Penalty
Summary
The facility failed to ensure that residents with enteral feeding tubes received appropriate treatment and services to prevent potential complications. This deficiency was identified for two residents, R13 and R35, based on a review of facility policy, clinical records, observations, and staff interviews. The facility's policy on the care and treatment of feeding tubes required adherence to current clinical standards and physician orders, including monitoring tube placement and preventing complications. Resident R13, who had a history of high blood pressure, heart failure, and COPD, was admitted with a feeding tube and had orders for enteral feeding. However, the medication administration records for March and April 2025 did not include orders for checking tube feeding residuals or elevating the head of the bed during feeding until April 15, 2025. The Director of Nursing confirmed that these orders were missing prior to this date. Resident R35, with diagnoses including major depressive disorder, adult failure to thrive, and dysphagia, also had a feeding tube. Observations revealed that the enteral feeding formula was incorrect and undated, and the feeding pole and surrounding area were dirty with spilled formula. The medication administration records for March and April 2025 similarly lacked orders for verifying tube placement, checking residuals, and elevating the head of the bed until April 15, 2025. The Nursing Home Administrator and Director of Nursing confirmed the facility's failure to provide appropriate treatment and services for these residents.
Plan Of Correction
1. Residents suffered no negative outcomes. 2. Orders were updated on residents with tube feeding to check tube feed residuals and elevating head of bed during administration. 3. Whole house audit was conducted on correct tube feed formula being hung and physician's orders relating to checking tube feed residuals and elevating head of bed during administration. 4. DON/designee to educate licensed staff on enteral feeding policies and enteral feeding physician's orders. 5. DON/designee to audit tube feed formula accuracy, labeled/dated, and appropriate orders 3x/week for 3 weeks, then 2x/week for 2 weeks, and 1x/week for 2 weeks. 6. Results to be submitted to QAPI for review and approval.