Failure to Label and Discard Enteral Feeding Containers
Penalty
Summary
The facility failed to ensure that a resident receiving enteral nutrition via a feeding tube received appropriate treatment and services to prevent complications. Specifically, the feeding formula and water containers used for a resident with a gastrostomy tube were not labeled with the required identifiers, such as the resident's name, date, and time of infusion. Observations showed that the containers remained hanging from the feeding pole after the feeding was completed, and the feeding pump was turned off. Staff interviews confirmed that the containers were supposed to be labeled to ensure correct administration and to track how long the formula had been in use, but this was not done. Additionally, staff indicated uncertainty about the time frame for the resident's nocturnal feedings and whether the remaining formula and water could be reused. The resident involved was a female with a history of cerebral infarct, aphasia, dysphagia, gastro-esophageal reflux, and gastrostomy status, and was assessed as severely cognitively impaired. Physician orders specified the administration of enteral feedings and water flushes at set times and rates. Facility policy required that all feeding equipment be labeled and changed according to specific guidelines, but these procedures were not followed. The Director of Nursing acknowledged that the formula should be labeled and discarded after 24 hours, and failure to do so could result in the use of outdated formula.