Failure to Dilute Medications and Label/Discard Enteral Feeding Containers
Penalty
Summary
A deficiency was identified when a resident with a gastrostomy tube did not receive appropriate care during medication administration and enteral feeding. The resident, who had diagnoses including pneumonia, gastro-esophageal reflux, heart failure, and was dependent on a feeding tube, was observed receiving medications that were not diluted before being administered through the feeding tube. The nurse administered undiluted liquid and crushed medications directly into the tube, flushing with only small amounts of water between each medication, contrary to facility policy and physician orders. Additionally, the containers used for the resident's feeding formula and water were not labeled with the required identifiers such as the resident's name, date, time, or nurse's initials. These containers were observed hanging at the bedside after the feeding was completed, rather than being discarded as required. Interviews with nursing staff confirmed that labeling and timely disposal of feeding containers were not consistently performed, and staff acknowledged the importance of these practices for resident safety and compliance with facility protocols. Facility policy required that medications be diluted with water before administration via feeding tube and that feeding formula containers be labeled and discarded after use. The Director of Nursing confirmed that these steps were necessary to prevent tube blockage and ensure the resident received the full benefit of medications and safe nutrition. The failure to follow these procedures was directly observed and confirmed through staff interviews and record review.