Untrained Nurse Aides Managed Tube Feeding, Breaching Facility Policy
Penalty
Summary
The facility failed to ensure that only competent, trained staff managed tube feeding pumps and tubing for a resident who was dependent on enteral nutrition. The resident, who had a history of stroke, dysphagia, muscle weakness, and epilepsy, was dependent for activities of daily living and received more than half of their nutrition through tube feeding. During morning care, two nurse aides (NAs) paused and disconnected the resident's tube feeding, leaving the uncapped end of the tubing hanging over the pole and later allowing it to touch the floor. One NA wiped the tubing with a tissue before reconnecting it to the resident and restarting the pump, despite not having received formal training on tube feeding management or pump operation. The NA expressed uncertainty about proper infection control procedures and indicated that nurses had only shown them how to pause the pump. Interviews with multiple staff members, including NAs, LPNs, an RN, and the DON, confirmed that NAs were not trained or authorized to operate tube feeding pumps or to connect/disconnect tube feeding tubing. Facility policy specified that only licensed staff should perform these tasks, and there was no record of NAs receiving education or competency checks related to tube feeding management. The deficiency was identified through observation, interview, and record review, demonstrating a lack of adherence to facility policy and proper staff training regarding tube feeding care.