Failure to Meet Professional Standards in Medication Management and Tube Feed Labeling
Penalty
Summary
Two deficiencies were identified in the facility's provision of care as outlined by the comprehensive care plan. For one resident with chronic respiratory failure, COPD, and cognitive communication deficit, Fluticasone-Salmeterol Inhalation Aerosol Powder was observed left unattended on the bedside table. The resident reported that staff typically removed the medication after use but sometimes forgot to do so. Review of the medical record confirmed the medication was to be administered twice daily, and interviews with nursing staff and the Director of Nursing confirmed that medications should not be left at the bedside unless there is a physician's order and a self-administration assessment has been completed. No such order or assessment was documented for this resident. In a separate incident, another resident with a history of nontraumatic intracranial hemorrhage, aphasia, quadriplegia, and hydrocephalus was observed with an unlabeled and undated tube feed bag. The resident was on a continuous enteral feeding regimen, and staff interviews confirmed that all tube feeds should be labeled with the date, time started, and the nurse's initials. The Director of Nursing also stated that tube feed bags and tubing should be replaced every 24 hours and labeled accordingly. The lack of labeling on the tube feed bag was not in accordance with these professional standards.