Failure to Label Enteral Feeding Formula Bag
Penalty
Summary
The facility failed to ensure that the enteral tube feeding formula bag for one resident was labeled with the date and time it was opened and hung, as required by the facility's policy and procedure for enteral feeding monitoring. During observation, an opened bag of Fibersource formula was found hanging from an IV pole next to the resident's bed, with the feeding tubing placed inside the feeding pump and ready for infusion. There was no open date indicated on the formula bag, and the licensed vocational nurse present was unable to state when the bag was opened or if it was expired. The nurse confirmed that the bag should have been labeled with the date and time, and acknowledged not knowing when the current bag was started. The resident involved had a history of dementia and gastrostomy, with severe cognitive impairment and dependence on staff for all activities of daily living. The physician's orders specified the administration of tube feeding at a set rate and schedule. The facility's policy required licensed nurses to write the time, date, and rate on the formula bottle, and to discard closed system formula after 48 hours. The lack of labeling on the formula bag meant staff could not determine if the formula was still safe for use, which was confirmed by both the nurse and the Director of Nursing during interviews.