Failure to Label Enteral Feedings and Incomplete Assessment After Change in Condition
Penalty
Summary
Facility staff failed to ensure that a tube feeding container and water flush for a resident receiving enteral nutrition were properly labeled with the resident's name and date. During an initial tour, a resident was observed with an enteral feed and water flush running, neither of which were labeled as required. A registered nurse confirmed that the containers should have been labeled with the appropriate information, but this was not done at the time of observation. Additionally, staff did not follow professional standards when caring for a resident who experienced a change in condition. A family member found the resident unresponsive and called 911 after being told by staff that the resident had been in that state all day. Medical record review showed that the resident was previously documented as alert and responsive, but there was no nursing assessment documented for the day shift when the change in condition occurred. The physician later noted the resident was confused and disoriented, and hospital records confirmed the resident was admitted with altered mental status, a urinary tract infection, and a positive COVID test.