Failure to Label Enteral Feeding per Facility Policy
Penalty
Summary
Surveyors found that the facility failed to follow its own policy and current professional standards for enteral feeding administration for one resident with a feeding tube. The facility’s policy, revised 2/24/25, required staff to fill in the container’s label with the patient’s name, room number, date, start time, and flow rate, and to label the administration set with the start date and time. The resident, admitted on 6/20/25 with stroke, dementia, dysphagia, adult failure to thrive, and severe protein-calorie malnutrition, had an admission MDS on 6/27/25 documenting use of a mechanically altered diet with a feeding tube, and a care plan dated 8/20/25 noting an enteral feeding tube to meet nutritional needs. On 9/2/25 at 10:57 AM, direct observation showed that Jevity 1.2 cal tube feeding was infusing via pump for this resident, but the Jevity bottle was not labeled with the date, time, or initials of the staff who started the infusion, contrary to facility policy. During an interview at 12:54 PM the same day, an RN stated that the overnight shift hangs the feeding and is supposed to date, time, and initial it, and confirmed that this information was missing from the resident’s tube feeding container. These findings were later reviewed with the nursing home administrator and quality manager during the exit conference on 9/9/25.
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