Failure to Verify Feeding Tube Placement
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of feeding for a resident who was reviewed for feeding management. The resident, identified as Resident #43, was admitted with several diagnoses, including severe cognitive impairment, and required tube feeding for nutrition and hydration. The facility's policy required checking the placement and patency of the feeding tube before each feeding or medication administration. However, during an observation, a Licensed Practical Nurse (LPN) connected the feeding tube to the resident without verifying the tube's placement or patency, contrary to the facility's policy. The resident's care plan highlighted the risk of complications due to the tube feeding status and included specific interventions to mitigate these risks, such as checking tube placement and providing flushes as ordered by the medical doctor. Despite these directives, the LPN did not perform the necessary checks before initiating the feeding, which could potentially lead to complications. The LPN later stated that she had checked the tube between 12:00 PM and 1:00 PM during medication administration, but this did not align with the requirement to check before each feeding connection.
Plan Of Correction
The statement made on this Plan of Correction are not and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all federal and state regulation the center has taken or will take the actions set forth in the following plan of correction. The following plan of correction constitutes the centers allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date indicated. Immediate Corrective Action: On resident #43 was assessed by the Director of Nursing, for signs of feeding intolerance, placement and residual. Resident #43 was tolerating feeding ok, placement was confirmed with no residual. On , Re-education on feeding administration was immediately provided to staff A, the licensed Practical Nurse. Identification of other residents potentially affected: Current residents have the potential to be affected; however, based on the residents assessment and observation completed, no resident was affected. Measures: On staff A was provided with competency skills training on Feeding Administration by the Director of Nursing. a. Verifying the five rights of administration b. Safety & Proper Positioning c. Tube Placement d. Residual e. Flush f. Control On , Relias training was completed by staff A, on feeding. Inservice/training will be completed for newly hired licensed nurses. Monitoring: The Director of Nursing/nursing team will complete daily audits for 4 weeks and then weekly x 2 months to ensure licensed nurses follow the policy and procedure for and provide appropriate treatment and services to prevent complications of feeding. The Director of Nursing will report the findings to the Quality Assurance Performance Improvement Committee Monthly X 3 months or until the committee determines substantial compliance.