Failure to Administer Ordered Tube Feed Rate and Label Feeding Bag
Penalty
Summary
The facility failed to ensure that a resident receiving continuous tube feeding was administered the correct ordered amount and rate of tube feed, as well as failed to properly label and date the tube feed bag. Specifically, the resident, who had diagnoses including gastrostomy status, dysphagia, and adult failure to thrive, was observed to have their tube feed infusing at 45 mL/hr instead of the physician-ordered rate of 50 mL/hr. The facility's policy required verification of the enteral nutrition label against the order before administration, including documentation of the date, time, and initials on the formula label, but this was not followed. During multiple observations, the tube feed was found running at the incorrect rate and without a label or date. Interviews with staff revealed that the LPN did not verify the correct rate with the off-going nurse during shift change, and the Director of Nursing confirmed that both off-going and incoming nurses are required to check tube feed orders during shift changes. The resident's medical record and nutrition notes confirmed the prescribed feeding regimen, which was not adhered to during the observed period.