Failure to Change Tube Feeding Bag and Tubing as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with a feeding tube received appropriate care and services as required. The resident, who had multiple diagnoses including acute respiratory failure, pneumonia, stroke, and a tracheostomy, was admitted with orders for tube feeding using a specific formula and instructions to change the feeding bag and tubing daily at 4:00 PM. Despite these orders and best practice guidelines stating that open system tube feeding containers and tubing should be changed at least every 24 hours, observations revealed that the tube feeding bag in use was dated several days prior and had not been changed as required. Staff interviews confirmed that the tube feeding bag and tubing were not changed on multiple consecutive days, even though documentation indicated otherwise. Staff acknowledged awareness of the missed changes and described the associated risks, including bacterial growth and potential for gastrointestinal issues. The Director of Nursing Services also confirmed that the bag and tubing should have been changed daily according to orders and best practices.