Failure to Label Tube Feeding Formula Bag
Penalty
Summary
A deficiency was identified when a tube feeding formula bag used for a resident with a history of cerebral palsy, dysphagia, and other significant medical conditions was found to be unlabeled during an early morning observation. The bag, which was actively infusing formula via a pump, lacked essential information such as the resident's name, room number, date and time the feeding was hung, the type or brand of formula, and the rate of infusion. The resident's care plan and physician orders specified the need for enteral feedings and water flushes, and the resident was dependent on staff for these interventions due to cognitive and physical impairments. Interviews with nursing staff revealed that the day shift LPN had transferred the formula from its original container to a disposable bag due to equipment incompatibility and typically used stickers to label the bags. However, the sticker was either not applied or had fallen off, and the LPN did not reinforce the label or write directly on the bag as she had done previously. The night shift LPN, upon removing the bag, confirmed it was unlabeled and could not identify the formula type. The Assistant Director of Health Services confirmed that facility policy required all tube feeding bags to be labeled with specific information, which was not followed in this instance.