Failure to Properly Label and Administer Tube Feedings as Ordered
Penalty
Summary
The facility failed to provide appropriate care and services to a resident receiving tube feedings. Observations revealed that the Isosource supplement bag and fluid/flush bag used for the resident's enteral feeding were not labeled or date marked as required by facility policy. Staff interviews confirmed that the bags should have contained stickers indicating the contents and the date and time they were hung, but neither bag was properly labeled at the time of observation. The facility's policy mandates that all feeding containers be labeled with the date and time started, and that any supplementary feeding withheld must be documented with a reason in the medical record. Review of the resident's clinical record showed multiple instances where the total volume of tube feeding administered was less than the physician-ordered amount, with no documentation in the progress notes explaining the shortfall. The resident had significant medical conditions, including traumatic brain injury, paraplegia, dysphagia, aphasia, anxiety, and depression. Despite clear physician orders specifying the formula, rate, and total volume to be infused, as well as water flushes, the facility did not consistently meet these requirements or document reasons for deviations. This lack of adherence to policy and physician orders led to the deficiency.