Expired and Unlabeled Enteral Feeding Formula Used for Tube-Fed Resident
Penalty
Summary
The facility failed to ensure appropriate care and services for a resident receiving enteral feeding, in accordance with its Enteral Feeding Tube Policy. The policy stated that licensed clinicians with demonstrated competence may administer enteral feedings and provide tube/site care. The resident involved had diagnoses including gastrostomy status, unspecified protein-calorie malnutrition, and dysphagia, and had physician orders for pump feeding to begin in the evening with a specified rate and total volume, and an order to take down the tube feeding each morning. The resident’s comprehensive care plan identified nutritional issues related to dysphagia, protein-calorie malnutrition, and the need for a feeding tube, with an intervention to provide tube feeding supplement with water flushes as ordered. Surveyor observations on one morning showed that the resident’s enteral feeding bag was hanging and infusing, but the bag was not labeled with a hang time or date. The same bag displayed a use-by date that had already passed and instructions stating it should be used for a maximum of 48 hours after connection when proper technique is followed. A later observation the same morning found the same unlabeled, nearly empty bag still hanging, though not infusing, with the same expired use-by date. An RN confirmed that this was the same bag she had disconnected from the pump and stated she had not hung it the previous day. During the interview, she became aware the formula was expired and located two additional expired formula bags in the resident’s room. The DON stated she would expect tube feeding formulas in use to be labeled with a hang time and date and not be expired.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.