F0693

D

Failure to Timely Replace and Label Enteral Feeding and Water for PEG Tube

Huntingdon, Tennessee Survey Completed on 01-07-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the facility’s care and services for a resident with a percutaneous endoscopic gastrostomy (PEG) tube when staff failed to replace and label enteral feeding and flush solutions in accordance with policy and clinical standards. The facility’s policy dated 10/15/2024 stated that feeding tubes would be maintained according to current clinical standards of practice with interventions to prevent complications. The resident involved was admitted with diagnoses including gastrostomy status, diabetes, seizures, and dementia, and a quarterly MDS assessment documented that the resident was rarely/never understood and required the use of a feeding tube. Physician’s orders directed continuous Jevity 1.5 enteral feeding at specified hourly rates and water flushes via PEG tube.

During observations on multiple occasions over two consecutive days, surveyors noted that the water flush solution and tube feeding were not changed within a 24-hour period and were not properly labeled. On the first day of observation, a clear bag of water infusing via feeding pump was dated two days earlier. On the second day, Jevity 1.5 tube feeding infusing via pump was dated the previous morning, and a clear bag of fluids labeled only with “H2O” had no label, date, or time. In an interview, the DON stated that night shift staff were believed to be responsible for changing tube feeding bottles, tubing, and water, acknowledged that tube feedings and water should not be hung and infusing for more than 24 hours, and confirmed that all tube feedings and water should be labeled and dated.