Failure to Accurately Document Enteral Feeding and Residual Checks
Penalty
Summary
The facility failed to maintain accurate and complete medical records for one resident receiving enteral nutrition via a PEG tube. According to the facility's policies and the LPN job description, staff are required to document the date, time, and amount of gastric residual volume (GRV) checks, as well as the administration times of enteral feedings. For the resident in question, physician orders specified a continuous feeding regimen with specific start and stop times. However, documentation inconsistencies were identified: the LPN recorded that the resident's enteral feedings were restarted at a certain time, but subsequent observations and interviews revealed that the feeding pump was off and the tubing was not connected at that time. The LPN later acknowledged that the documentation indicating the feeding had been restarted was inaccurate. Further, when the LPN performed a GRV check and later restarted the resident's enteral feeding, these actions were not documented in the resident's medical record as required. The nurse's notes lacked entries for the actual time the feeding was restarted and for the GRV check, including the date, time, and amount. The DON confirmed that the LPN should have accurately documented all relevant information regarding the resident's enteral feeding and residual checks, in accordance with facility policy and professional standards.