Failure to Change Tube Feeding Solution and Tubing per Policy
Penalty
Summary
The facility failed to provide appropriate care and services to prevent complications related to enteral feeding for a resident who was dependent on tube feeding. The facility's policy and the formula manufacturer's guidelines required that enteral feeding solutions and tubing be changed every 24 hours to prevent bacterial growth and potential infection. However, observation revealed that a tube feeding solution and water flush, both dated several days prior, were still hanging in the resident's room and had not been changed according to policy. The feeding solution and water flush were dated for three days prior to the observation, and neither was connected to the resident at the time. Interviews with nursing staff, including RNs and LPNs, confirmed that the standard practice was to change tube feeding solutions and tubing every 24 hours. Staff acknowledged the importance of this practice to prevent the solution from spoiling and to avoid the risk of infection or food poisoning. Despite this, there was uncertainty among staff regarding the continuation of orders and the timing of solution changes, with some unable to recall when the solution was last changed or why it was still hanging with an outdated date. Further interviews with the Infection Preventionist Nurse and the DON confirmed that the facility's expectation was for tube feeding solutions and sets to be changed every 24 hours, and that failure to do so could result in bacterial growth and resident illness. The DON and other leadership were not aware that the outdated solution was still present in the resident's room, indicating a lapse in monitoring and communication regarding adherence to enteral feeding protocols.