Failure to Properly Label, Date, and Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to properly label, date, and administer tube feeding as ordered for a resident with significant medical needs. The resident, who had diagnoses including non-traumatic brain dysfunction, stroke, and high blood pressure, was assessed as having severely impaired cognition and was dependent on staff for all activities of daily living, including eating. Observations over two days showed the resident receiving tube feeding at a rate of 40 ml/hr, while the physician's order specified a rate of 45 ml/hr. There was no documentation in the progress notes or orders to justify the deviation from the prescribed rate. Additionally, the tube feeding formula bag in use was observed to be dated from the previous day, exceeding the facility's policy to change the bag every 24 hours. Interviews with nursing staff and the DON confirmed that the policy requires tube feeding bags to be changed and dated every 24 hours and that physician orders should be followed precisely. The facility's own policy also mandates that tube feedings be administered according to current clinical standards and physician orders, including specific instructions for feeding type, rate, and bag changes.