Failure to Properly Label and Administer Enteral Feedings and Water Flushes
Penalty
Summary
Surveyors identified multiple deficiencies related to the administration and labeling of enteral feeding and water flush bags for residents with feeding tubes. In several cases, staff failed to label water flush bags and formula bottles with essential information such as the resident's name, room number, administration rate, date and time hung, and the initials of the licensed nurse. For example, one resident's water flush bag lacked the resident's name, room number, and infusion rate, and the staff confirmed that both the tube feeding bottles and water flush bags should be labeled with this information to ensure correct administration. Another resident's formula bottle was labeled with an incorrect administration rate that did not match the rate set on the feeding pump, and the water flush bag was also missing required identifying information. The report details that these labeling failures were observed across multiple residents, all of whom had significant cognitive impairments and required total assistance with activities of daily living. The residents had complex medical histories, including tracheostomies, ventilator dependence, gastrostomies, dysphagia, and protein-calorie malnutrition. Staff interviews confirmed that the facility's policy required specific labeling to prevent errors in administration and to ensure that residents received the correct formula and hydration as ordered by physicians. However, observations and record reviews revealed that these protocols were not consistently followed. Additionally, the facility's own policies and procedures, which were reviewed by surveyors, clearly outlined the steps necessary to ensure safe administration of enteral nutrition, including checking the label against the order and documenting all required information. Despite this, staff did not consistently adhere to these protocols, as evidenced by the lack of proper labeling and mismatched administration rates. These deficiencies were confirmed through direct observation, staff interviews, and review of facility policies.