Failure to Follow Enteral Feeding Protocols and Labeling Requirements
Penalty
Summary
Staff failed to follow facility protocols for the care and administration of enteral nutrition for two residents with gastrostomy tubes. For one resident with severe cognitive impairment and a history of dysphagia and malnutrition, observations revealed that the feeding formula and water flush bag were not labeled with the time they were hung or the rate of infusion, as required by physician orders and facility policy. Additionally, a specialized valve used with the feeding tube was disconnected and left uncapped, hanging from the feeding pump pole, contrary to infection control protocols. Interviews with nursing staff and the Director of Nursing confirmed that these labeling and handling procedures were not followed, which are necessary to ensure accurate administration and prevent contamination. For another resident with hemiplegia, aphasia, and severe cognitive impairment, the water flush bag was observed without the required label indicating the administration rate and frequency. Nursing staff acknowledged that the label should have included this information to ensure the resident received the correct amount of water flushes as ordered by the physician. The Director of Nursing confirmed that the omission of this information on the label did not comply with facility policy and could result in the resident not receiving the prescribed hydration. Record reviews for both residents showed clear physician orders for the administration of enteral nutrition and water flushes, specifying rates, frequencies, and labeling requirements. Facility policy and procedures also outlined the need for accurate labeling and safe handling of enteral feeding equipment to prevent errors and contamination. Despite these protocols, staff did not consistently implement them, as evidenced by direct observations and staff interviews.