Failure to Change and Label Tube Feeding Syringe per Policy
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policies and procedures for tube feeding equipment management for one resident. During a room tour, a surveyor observed a tube feeding syringe hanging on a pole next to the resident’s bed in an opened package dated 7/25, with no label indicating the resident’s name. The resident stated they were unsure how old the syringe was and requested a new one if needed. The resident’s face sheet documented multiple medical diagnoses, including multiple sclerosis, gastrostomy status, urinary incontinence, neuromuscular dysfunction of the bladder, and urinary tract infection. A BIMS score of 12 indicated moderately impaired cognition. The resident’s care plan documented that nutritional needs were not met by oral feeding and that tube feeding was required related to a diagnosis of multiple sclerosis. The resident’s active physician orders included enteral bolus feedings of Jevity 1.5 twice daily with specified volume, and water flushes before and after each bolus feeding. The DON stated that tube feeding syringes should be changed every 24 hours to prevent infection. Facility policy titled “Gastric Tube Feeding” specified that the syringe for flushing is to be changed daily and labeled with the resident’s name and date. Another facility policy, “Equipment Change Schedule Policy,” documented that piston syringes are to be changed daily, every 24 hours. Despite these policies and orders, the observed syringe remained in use beyond 24 hours and was not labeled with the resident’s name, constituting the failure to ensure proper tube feeding syringe change and labeling for this resident.
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