Failure to Ensure Proper Enteral Feeding Administration and Storage
Penalty
Summary
The facility failed to ensure proper management and administration of enteral feeding services for two residents. Surveyors observed expired enteral feeding formula bottles stored in the subacute storage unit, which was confirmed by Central Supply staff. Additionally, the facility's policy required the head of the bed (HOB) to be elevated at least 30 degrees during enteral feeding to prevent complications, but this was not consistently followed. For both residents reviewed, medical records indicated they lacked capacity to make medical decisions and had physician orders specifying HOB elevation between 30 to 45 degrees during feedings. Direct observations showed that both residents were receiving enteral tube feedings with the HOB elevated less than 30 degrees. Nursing staff and the DON acknowledged that the HOB was not properly elevated during feedings, and the facility did not have a device to measure the exact angle of elevation. These failures were confirmed through interviews and concurrent observations with nursing staff, who verified that the required procedures were not followed during the administration of enteral feedings.