Failure to Label and Replace Enteral Feeding Supplies
Penalty
Summary
The facility failed to ensure proper labeling and timely replacement of piston syringes and distilled water containers used for enteral feeding and flushing in multiple residents with gastrostomy tubes. Surveyors observed that piston syringes at the bedsides of several residents were not labeled with the date they were changed, and containers of distilled water used for flushing G-tubes were not marked with the date they were opened. Staff interviews confirmed that the expectation was for these items to be labeled and changed daily to maintain infection control, but this was not consistently done. For one resident with a G-tube and severe cognitive impairment, a piston syringe container was found unlabeled, and the distilled water used for flushing the tube was also not dated. The care plan and facility policy required daily changes and labeling of these items, but staff acknowledged that this was not always followed. Another resident, who was alert but unable to communicate, also had an unlabeled feeding tube piston syringe at the bedside. Staff stated that syringes should be labeled and changed regularly to prevent bacterial growth, but this was not observed in practice. A third resident's room was found to have a tube feeding syringe and an enteral tube feeding adaptor placed loosely on the bedside table, both not contained or labeled, and an open gallon of distilled water without an open date. Staff interviews reiterated that all such items should be labeled and changed daily, and that adaptors should be kept with the patient and not left out. The lack of labeling and proper containment of these items was confirmed by multiple staff members, including the DON and ADON, as not meeting facility expectations for infection control.