Failure to Implement Dietician Recommendations and Properly Label Enteral Feeding Supplies
Penalty
Summary
The facility failed to ensure appropriate enteral feeding practices for a resident receiving tube feedings. Observations revealed that the resident's Glucerna 1.5 tube feeding was infusing via a pump, but the bottle was not labeled with the date it was opened, and the water flush bag lacked both a name and date label. A licensed nurse was unaware of when the Glucerna bottle was opened, as it was already infusing at the start of her shift. Additionally, the water flushes were not set at the correct rate as ordered by the physician. Review of the clinical record showed that the registered dietician had recommended an increase in the tube feeding rate due to the resident's weight loss, but this recommendation was not implemented. The dietician stated she communicated her recommendations to the Director of Nursing, who was responsible for entering the order, but was unaware that the changes had not been made. The facility's policy required that recommendations from the dietician be communicated and followed up with appropriate documentation, which did not occur in this instance.