Failure to Change Water Flush Bag Every 24 Hours for Resident with Feeding Tube
Penalty
Summary
The facility failed to ensure appropriate care and services for a resident with a gastrostomy tube by not changing the water flush bag every 24 hours as required by facility policy. The resident, who had severe cognitive impairment and was rarely or never understood, was receiving tube feedings and scheduled water flushes through an enteral feeding pump. Observations revealed that the water flush bag in use had not been changed for over 56 hours, and subsequent review showed it remained unchanged for more than 62 hours. The facility's policy specified that open system bags and tubing may hang for up to 24 hours unless compromised, but this was not followed in the resident's care. Interviews with nursing staff and facility leadership confirmed that water flush bags should be changed every 24 hours, typically when a new tube feeding container is connected. However, both night and evening shift nurses believed it was the other shift's responsibility to change the bag, resulting in the task being overlooked. There was no documentation in the resident's nursing progress notes to explain the failure to change the water flush bag as required, and physician orders did not specify the frequency for changing the water flush bag.