Failure to Accurately Label and Store GT Feeding Formulas
Penalty
Summary
The facility failed to provide necessary gastrostomy tube (GT) care and services for two residents receiving enteral feeding. Observations revealed that the GT feeding formulas for both residents were not labeled accurately according to the physician's orders, with discrepancies in the feeding rates written on the labels compared to the orders in the medical records. Additionally, the date and time when the formula was hung were missing from the labels. Both residents had unopened bags of their respective feeding formulas stored at their bedsides, contrary to facility policy, which requires unopened formulas to be stored in temperature and light-controlled conditions within a locked utility room. Interviews with nursing staff and the Director of Nursing (DON) confirmed that the labels on the GT feeding formulas did not match the physician's orders and that the storage of unopened formula at the bedside was not in accordance with facility policy. The DON stated that proper labeling is necessary to ensure the correct resident, rate, and formula are administered, and that unopened formulas should be stored in the utility room. The observed practices did not align with the facility's written policies and procedures for enteral feeding safety precautions and error prevention.