Failure to Monitor and Document Enteral Feeding Care and Adherence to Protocols
Penalty
Summary
The facility failed to provide necessary gastrostomy tube (GT) care and services for two residents receiving enteral feeding. For one resident, staff did not monitor or document intake and output as required by both the resident's care plan and the facility's policy. The resident had a history of dysphagia and was receiving Glucerna via GT at a prescribed rate. Despite a care plan intervention to monitor intake and output, there was no evidence in the medical record that this was being done. Interviews with staff, including an LVN and the DON, confirmed that intake and output monitoring was not consistently performed or documented for residents on tube feeding, contrary to facility protocol and care plan requirements. For another resident, the facility did not ensure that the enteral feeding formula was changed within 24 hours, nor was the formula bottle properly labeled with the start time and nurse's initials. Additionally, the water bag used for enteral feeding was not labeled with the date and time it was prepared. This resident also had a history of dysphagia and was receiving Jevity 1.2 via feeding pump, along with scheduled water flushes. Observation and interviews confirmed that the labeling and timely changing of the formula and water bag were not performed as required by facility policy. These deficiencies were identified through observation, interviews, medical record review, and review of facility policies and procedures. Both the DON and Administrator acknowledged the findings related to the lack of intake and output monitoring, as well as the failure to follow protocols for changing and labeling enteral feeding supplies.