Failure to Administer Correct Enteral Feeding Formula
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding was provided with the correct treatment and services to prevent complications. Specifically, a resident was administered the wrong enteral formula, Glucerna 1.5, instead of the prescribed Glucerna 1.2. The bottle containing the enteral formula lacked a label with the resident's name, flow rate, and the time and date of administration, which is against the facility's policy. This oversight was observed during a survey, where it was noted that the feeding had been started the previous day and was leaking at the time of observation. The resident in question had a history of significant weight loss and was on a feeding tube, with a physician's order to change the formula to provide additional calories and protein. However, the nursing staff failed to update the feeding solution as per the new order. Interviews with the nursing staff revealed a lack of awareness regarding the change in the feeding solution order, although they were aware of the change in flow rate. The Director of Nursing Services confirmed that the tube feeding bottle should have been labeled correctly, and the nurses were expected to verify the physician's orders before administration.
Plan Of Correction
Plan of Correction: Approved April 14, 2025 I. Immediate Corrective Action The incorrect tube feeding formula (Glucerna 1.5) on Resident #123 was identified. The correct formula (Glucerna 1.2) as per the physician's updated order dated 3/13/2025 was initiated. The licensed nurse responsible for the deficient practice was identified and received disciplinary action. The resident's weight, tolerance to feeding, and nutritional intake were reassessed by the interdisciplinary team, including the Registered Dietitian and primary care provider. II. Identification of other residents A comprehensive audit was initiated and completed for all residents receiving enteral nutrition to: - Verify that the formula being administered matches the most current physician order. - Ensure that all enteral feeding containers are clearly labeled with resident identifiers, prescribed formula, flow rate, and time of administration. No negative findings were identified from this review. III. Systemic Changes The Enteral Nutrition Administration policy was reviewed and revised to reinforce: - The requirement that nurses must verify both the formula and flow rate against the physician’s most current order before administering or hanging tube feedings. - Mandatory labeling of every tube feeding bottle with the resident’s name, formula, flow rate, and time started. Mandatory in-service training will be conducted for all licensed nursing staff, focusing on: - Interdisciplinary communication related to order changes (e.g., from dietary to nursing). - Proper verification of tube feeding orders and documentation procedures. - Risks of administering incorrect formulas (e.g., weight loss, aspiration, metabolic imbalance). Nursing shift-to-shift handoff documentation was revised to include a checklist for enteral nutrition administration, including verification of the formula, rate, and labeling compliance. IV. QA Monitoring A Tube Feeding Audit Tool has been developed and will be utilized by the RN Supervisor or Designee as follows: - Weekly audits for four weeks to verify accurate formula administration, proper labeling, and correct documentation. - Thereafter, audits will be conducted monthly for three months or until sustained compliance is achieved. Audit results will be reported to the Director of Nursing. Staff found non-compliant will receive immediate re-education and may be subject to progressive disciplinary measures as needed. The Director of Nursing will continue to oversee adherence to the enteral nutrition protocols as part of ongoing performance improvement. Audit findings will be presented to the QAPI Committee during the quarterly meeting for review and determination of whether to continue with the audits. Responsible Party: Director of Nursing