Failure to Ensure Proper Tube Feeding Management and Documentation
Penalty
Summary
The facility failed to ensure proper management of tube feeding for a resident, resulting in complications and failure to maintain the resident's weight. During observation, a resident was found with leaking tube feeding, and staff responded without donning appropriate PPE beyond gloves. The staff cleaned the leaked feeding and adjusted the tube, but the process revealed issues with the administration and handling of the feeding equipment. Additionally, the suction container was improperly handled and disposed of in the sink, then returned to the bedside table. Further review showed that the prescribed tube feeding formula, Isosource 1.5, was unavailable for two days, and an alternate formula, Fibersource, was used without a new physician order or notification to the physician. The change in formula was not documented in the resident's orders, and the TAR inaccurately reflected that Isosource was administered. Daily weights, ordered to monitor the resident's status, were not documented as required, despite a recent significant weight loss. The facility's policy required weights to be obtained three times a week, but this was not followed.