Failure to Check J-Tube Placement and Label Enteral Feeding Bag
Penalty
Summary
A deficiency was identified when a nurse failed to check the placement of a resident's J-tube prior to administering medications and water flushes. The nurse administered 30 ml of water, a hydroxyzine cocktail, and another 30 ml flush before measuring the tube, contrary to physician orders that required tube placement to be checked by measuring before use. The nurse acknowledged the error, stating the measurement should have been done prior to medication administration. The resident involved had a diagnosis of Multiple Sclerosis and quadriplegia and was the only resident in the facility with a feeding tube. Additionally, the disposable tube feeding bag in use for the resident was not properly labeled. The bag was dated but did not indicate the type of feeding or the rate, as required. The Director of Nursing confirmed that the bag was not labeled with the type of tube feeding and questioned whether the rate should also be included. Physician orders specified the use of Jevity 1.5 at a set rate, but this information was not documented on the feeding bag. The facility's policy on enteral tube feeding did not address procedures for labeling disposable tube feeding bags.