Failure to Label and Manage Enteral Feeding Supplies
Penalty
Summary
The facility failed to ensure proper labeling and management of enteral feeding supplies for a resident with a percutaneous endoscopic gastrostomy (PEG) tube. Specifically, the water bag used for tube feeding was not marked with the date or time, and the syringe used for water flushes was not dated. These deficiencies were observed on multiple occasions, with the water bag and syringe both lacking required labeling while the resident was receiving internal feeding and water. Interviews with nursing staff revealed inconsistent understanding and practices regarding the labeling and changing of these supplies, with one nurse stating the syringe should be dated and changed weekly, while another stated the facility did not require dating and that supplies were changed daily. The resident involved had a history of severe cognitive impairment, was dependent on staff for all activities of daily living, and received all nutrition and hydration via a PEG tube due to being NPO. The resident's care plan included specific instructions for tube feeding and hydration, but the electronic medical record lacked clear direction for staff on when to change out the syringe for water flushes. Facility policy required safe practices for medication administration via enteral tubes, but the observed lack of labeling and inconsistent staff practices indicated a failure to follow these guidelines.