Failure to Label Tube Feeding Solution for Resident Receiving Enteral Nutrition
Penalty
Summary
The facility failed to provide appropriate care and services to a resident receiving tube feedings. Observation revealed that a bottle of tube feeding solution was hanging at the resident's bedside without any labeling to indicate the contents, the initials of the staff member who hung it, or the date and time it was started. The facility's policy on enteral management did not specify requirements for labeling tube feeding solutions with this information. The resident in question had diagnoses including acute kidney failure and diabetes, and had a physician's order for Glucerna 1.5 to be administered at a specific rate. A review of the resident's clinical record confirmed the presence of an order for Glucerna 1.5, and the plan of care noted the use of an enteral feeding tube. During staff interviews, an LPN stated she did not hang the tube feeding solution and was unaware of when it was started or by whom, and could not confirm the contents of the bottle. The Nursing Home Administrator stated that he would expect the tube feeding solution to be labeled with the contents and the time/date it was hung, but this was not done in this instance.