Failure to Provide Continuous Tube Feeding and Proper Site Care
Penalty
Summary
Facility staff failed to ensure continuous tube feeding for one resident who was assessed as requiring total assistance for all activities of daily living and had a physician's order for Jevity 1.5 at 40 ml per hour, 24 hours a day. Observations revealed that the resident's tube feeding pump was not running and had been idle for at least 10 minutes on two separate occasions. The nurse responsible confirmed that the tube feeding was not running as ordered and had not been restarted within the last hour. Additionally, staff did not provide feeding tube site care according to the practitioner's orders for another resident with moderate cognitive impairment and total care needs. The treatment order specified cleansing the site and applying Vaseline gauze followed by split gauze twice daily. During observation, the old dressing was found to lack Vaseline gauze, and bright red blood was present at the insertion site. The LPN confirmed the absence of Vaseline gauze and that the old dressing had adhered to the resident's skin, causing discomfort.