Unlabeled Enteral Feeding Bags for Tube-Fed Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s enteral feeding bags were labeled with the contents and the date and time the feeding was started, as required by facility policy. The resident had diagnoses including muscle weakness, difficulty in walking, hypertension, dementia, and anxiety, with a BIMS score of 15 indicating intact cognition. The MDS documented that the resident had bilateral lower body impairment, was dependent on staff for toileting and bathing, had a feeding tube, and received 51 percent of her calories through tube feedings. The care plan and physician orders specified detailed enteral feeding procedures, including elevating the head of bed, checking tube placement and residuals, flushing the PEG tube with specified amounts of water, and changing and labeling the feeding syringe daily with name and date. The facility’s policy for administering nutritional formulas through an enteral tube required staff to label the bag and tubing with the date and time. Surveyor observations on multiple mornings showed the resident in bed with the head of bed elevated and the enteral feeding running via pump at the ordered rate, but the feeding bags were not labeled with the contents or the date and time the feeding was started. On one observation, the enteral feeding bags were hung on the feeding pump without any markings, and on subsequent observation the pump was running at 70 ml/hr with the bags still unlabeled. Interviews with a licensed nurse and an administrative nurse confirmed that night-shift nurses were responsible for hanging and labeling the bags with the date, time, rate, and formula, and that the bags should be marked on the back with the date and contents. Despite these stated responsibilities and the written policy, the resident’s feeding bags remained unlabeled during the surveyor’s observations, constituting the identified deficiency.
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