Failure to Accurately Document and Perform Feeding Tube Bag Changes
Penalty
Summary
The facility failed to accurately document and perform feeding tube treatments for a resident with significant medical conditions, including acute respiratory failure, pneumonia, stroke, and tracheostomy status. Physician orders required the resident to receive tube feeding formula with a new bag set up daily at a specified time. However, observation revealed that the tube feeding bag in use was labeled with a date several days prior, and staff confirmed that the bag and tubing had not been changed on multiple consecutive days, despite documentation in the Treatment Administration Record (TAR) indicating otherwise. Interviews with staff and review of records confirmed that the feeding tube bag and tubing were not changed as required, and the documentation was inaccurate.