Failure to Label Tube Feeding Flush Bag and Notify Clinicians of Significant Weight Gain
Penalty
Summary
The facility failed to meet professional standards of practice for two residents. For one resident with a history of traumatic subarachnoid hemorrhage, schizophrenia, dysphagia, and cognitive impairment, the tube feeding flush bag was observed to be unlabeled with the date and time it was hung. The bag contained approximately 450 ml of fluid remaining in a 1000 ml bag. Staff interviews revealed inconsistent understanding of labeling requirements, with one LVN stating that the flush and feeding were connected as a set and did not require separate labeling, while another LVN and the DON confirmed that the flush bag should have been labeled to ensure timely changes and prevent the use of expired fluids. Facility policy and lesson plans also indicated the need for labeling and dating G-tube supplies. Another resident, admitted with severe protein-calorie malnutrition, COPD, muscle weakness, obstructive sleep apnea, and gastrostomy, experienced a 6.2-pound weight gain over five days. The weight gain was not rechecked for accuracy, and the Registered Dietician (RD) and physician were not notified as required. The Restorative Nursing Assistant (RNA) acknowledged that the weight should have been rechecked and reported, and the Assistant Director of Nursing (ADON) admitted that the physician and RD should have been notified within 24 hours. The DON and RD both confirmed that the weight gain should have prompted immediate notification and further assessment. Facility policy required staff to report significant weight changes to the physician. The failure to label the tube feeding flush bag and to notify the RD and physician of significant weight gain represent lapses in following professional standards and facility protocols. These deficiencies were identified through observation, interviews, and record reviews, and were confirmed by multiple staff members, including the DON and RD.