Failure to Label Tube Feeding Formula for Resident Receiving Enteral Nutrition
Penalty
Summary
A resident with diagnoses of dysphagia and aphasia was admitted to the facility and required a gastrostomy feeding tube. During an observation, it was noted that the resident's tube feeding formula, Fiber source HN, was being administered at a specified rate but was not labeled as required. The lack of labeling was confirmed during interviews with a per diem licensed nurse and the Director of Nursing, both of whom acknowledged the importance of labeling for safety, accuracy, and adherence to physician orders. A review of the facility's policy on enteral feedings indicated that the formula label should include the resident's name, ID, room number, type of formula, date and time prepared, and initials of the person who hung the formula. The policy also requires verification of the label against the order before administration. The failure to label the tube feeding formula was identified through observation, interview, and record review, and was found to be inconsistent with facility policy and standard safety practices.