Failure to Label and Maintain Clean Enteral Feeding Equipment for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate labeling, dating/timing, and cleanliness of enteral feeding equipment for two residents receiving tube feedings. One resident had severe cognitive impairment, a history of CVA, and calorie-deficient malnutrition, and had physician orders for enteral feeding to be turned off at 9:00 AM. During observation late in the morning, this resident’s tube feeding was still running, and the pump alarm was sounding with an error message. An LPN who did not normally work on that hall silenced the alarm without knowing when the feeding had been started or how long it was supposed to run, and did not address the visibly dirty condition of the pump, pole, base, floor, and nearby chair and belongings, all splattered with a dried, sticky substance resembling tube feeding. Further observations showed that the same resident’s pump alarm continued to sound with an error code while the pump was not running, and multiple staff, including an RN, walked past the open room without responding to the alarm. The resident appeared frustrated, waving a hand with an angry expression. The order summary still indicated the enteral feeding was to be off at 9:00 AM, yet the feeding equipment remained in use and visibly soiled. A family member later reported that the visitor chair next to the bed had been covered with feeding tube drippings the previous day, which they stated had been dripping from the bottle. On a subsequent day, the resident’s enteral feeding and a bag of clear fluids were again observed hung on a pole and attached to the pump, with the pump, pole, base, floor, and a chair with a fleece jacket and ointment tube all splattered with a dried, sticky substance resembling enteral feeding. The second resident, who was cognitively intact and received nightly enteral feeding for duodenal obstruction and chronic vascular intestinal disorders, was observed with an enteral feeding container and a bag of clear fluids hung on a pole and connected through a pump. Neither the feeding nor the fluids were labeled with the resident’s name or with the date and time they were hung, despite the DON’s statement that tube feedings and fluids should be labeled with name, date, and time so staff would not reuse them and would know when they were hung. Later observation showed the feeding and fluids still partially full, with residual feeding in the tubing, and the pump, pole, base, and floor splattered with a dried, sticky substance resembling enteral feeding. On another day, the same resident’s pump, pole, base, and floor were again observed splattered with a sticky substance resembling enteral feeding. A unit manager confirmed that tube feeding and fluid should be dated and labeled to know when they were hung and if they were fresh, and that enteral feeding equipment should be kept clean for infection control.
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