Failure to Change Enteral Water Feeding Bag Within 24 Hours
Penalty
Summary
A deficiency was identified when the facility failed to provide necessary gastrostomy tube (GT) care and services for a resident receiving enteral feeding. Specifically, the facility did not change the resident's enteral water feeding bag within the required 24-hour period, as outlined in the facility's policy and procedure for enteral feedings. The policy, revised in November 2018, states that administration sets for open-system enteral feeding must be changed at least every 24 hours or as specified by the manufacturer. The resident in question had a medical history of dysphagia and lacked the capacity to make decisions. Medical orders indicated the resident was to receive Diabetisource AC formula and free water via GT. During an observation, it was noted that the enteral feeding water bag had been prepared more than 24 hours prior, and this was confirmed by an LVN, who acknowledged the bag should have been changed within the 24-hour timeframe. The DON also verified and acknowledged these findings.