Failure to Properly Label and Shake Tube Feeding Formula
Penalty
Summary
A deficiency occurred when staff failed to properly label and shake a new tube feeding formula bottle before administration to a resident with a history of stroke, dysphagia, and gastrostomy status, who was severely cognitively impaired and dependent on tube feeding for all nutrition and hydration. Facility policy required that tube feeding formula containers be shaken to ensure proper mixing and labeled with the type of formula, strength, amount, rate of administration, date, time, and initials of the nurse. During observation, the tube feeding bottle in use was found to lack date, time, and initials, and had visible sediment at the top, indicating it had not been shaken prior to hanging. Interviews with nursing staff revealed that the nurse responsible for hanging the bottle did not shake the formula and failed to label the bottle as required, citing being in a hurry at the end of her shift. Other staff confirmed the bottle was already hanging at the start of their shift and acknowledged the lack of labeling and shaking. The Director of Healthcare Services and the Administrator both confirmed that the bottle should have been shaken and labeled according to facility policy.