Failure to Ensure Safe and Appropriate Enteral Nutrition Administration
Penalty
Summary
The facility failed to ensure safe and appropriate administration of enteral nutrition and medication for two residents with feeding tubes. For one resident with diagnoses including atrial fibrillation, dementia, and hemiplegia, staff did not check gastric residual volume prior to starting enteral nutrition, did not maintain the head-of-bed at the required elevation during active feeding, and did not follow physician orders for flushing the feeding tube before and after medication administration. Specifically, the nurse admitted to not checking residuals before feeding, positioned the resident flat while feeding was infusing, and used an incorrect amount of water for flushing the tube. For another resident with cerebral palsy, epilepsy, and a developmental motor disorder, staff used enteral tubing that was left uncapped and undated at the bedside, which had not been properly protected from contamination. Despite the tubing being wiped with alcohol before use, the facility's Infection Preventionist confirmed that uncapped tubing should not be used and should be replaced. These actions were observed during surveyor visits and were not in accordance with facility policy or standard nursing procedures.