Failure to Ensure Proper Labeling and Storage of GT Feeding Formula
Penalty
Summary
The facility failed to provide appropriate care and services related to gastrostomy tube (GT) feeding for two residents. For one resident, the GT feeding formula (Glucerna 1.5) was observed stored at the bedside with 800 ml remaining in the bottle, and the bottle was not labeled with the resident's name or the date and time it was opened. Medical record review confirmed that the resident was receiving bolus GT feedings as ordered, and staff interviews verified that the formula bottle should have been properly labeled. Additionally, it was confirmed that the correct packaging (can or Tetra Pak) should be used to ensure accurate administration, but this was not followed. For another resident, a bottle of Jevity 1.5 Cal was observed left unattended at the bedside while the resident was receiving tube feeding. The physician's order specified the administration of Jevity 1.5 Cal at a set rate via enteral feeding pump. Staff interviews confirmed that an extra bottle of tube feeding formula should not be left at the bedside to prevent contamination, but this protocol was not followed. Both incidents were acknowledged by facility leadership during interviews.