Health inspection·June 1, 2023

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, medical record review, staff interview and policy review, the facility failed to change an enteral tube feeding after 24 hours. This affected one resident (Resident #227) of two residents (Resident #211 and #227) reviewed for enteral tube feedings. The facility identified four residents (#211, #225, #227, and #228) receiving enteral tube feedings. The facility census was 70. Findings include: Review of the medical record review for Resident #227 revealed an admission date of 01/03/23. Diagnoses included but were not limited to unspecified severe protein-calorie malnutrition, quadriplegia, autistic disorder, epilepsy, cerebral palsy, and schizophrenia. Review of 03/24/23 quarterly Minimum Data Set (MDS) 3.0 for Resident #227 revealed a Brief Interview of Mental Status (BIMS) score of 00 which indicated severe cognitive impairment. Review of activities of daily living (ADLs) revealed Resident #227 required extensive assist of two staff for bed mobility, transfer, toileting, total dependence of one staff for dressing, personal hygiene, and extensive assist of one staff for eating. Resident #227 was noted to receive an enteral tube feeding and mechanically altered diet. Review of the 01/04/23 physician's order for Resident #227 revealed an order to change enteral feeding syringe and tubing nightly, label and date tube feeding supplies nightly. Review of the 03/15/23 physician's order for Resident #227 revealed an order for Novasource Renal at 38 milliliters per hour continuous. Observation on 05/30/23 at 12:34 P.M. revealed Resident #227's open system plastic enteral tube feeding bag with a handwritten date of 05/29/23 and 5 A.M. below it. No additional writing was on the bag to identify the product inside. The plastic bag hanging on the other side of the medication administration pole which contained the syringe was also dated 05/29/23. The enteral tube feeding was running at 38 milliliters per hour. Interview on 05/30/23 at 12:58 P.M. with Registered Nurse #311 confirmed the enteral tube feeding was dated 05/29/23 with 5:00 A.M. below it as well as the bag containing the syringe and stated he did not know why it had not been changed by the night shift. Interview on 05/31/23 at 3:23 P.M. with the Director of Nursing (DON) stated the facility used the tetra pak cartons of Novasource Renal from Nestle for Resident #227. The DON confirmed that the facility opens the tetra pak containers of Novasource Renal product and pours them into the disposable Page 1 of 2 366454 366454 06/01/2023 Avenue at Macedonia 9730 Valley View Road Macedonia, OH 44056

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few tube feeding bag. The DON provided a Hang Time Guidelines for Using Open and Closed Tube Feeding Systems guidelines sheet from Nestle that indicated The American Society for Parenteral and Enteral Nutrition (ASPEN) Safe Practices for Enteral Nutrition therapy for an open system or tetra pak cartons provide the following hang time recommendations: for a commercially sterile, liquid formulas decanted from a carton, an eight-hour hang time is recommended . Higher degrees of contamination have been found in reconstituted powdered formula and in open systems allowed to hang for extended periods of time (greater than 21 hours). The DON confirmed opening the cartons and pouring the product into the plastic tube feeding bag was considered an open system. Review of the Novasource Renal tetra pak eight fluid ounce container for enteral feedings revealed Nestle Health Science if the manufacturer. Review of the Nestle Health Science Your-Guide-To-Home-Tube-Feeding revealed the term formula hang time refers to how long a tube feeding formula should remain at room temperature for feeding after the formula has been opened or the original package seal has been broken. The recommended hang time for open system formulas is up to eight hours for ready to use liquids. Your-Guide-to-Home-Tube-Feeding.pdf (nestlehealthscience.ca) The following deficiency was cited relative to incidental findings that were discovered during this complaint investigation completed on 06/01/23. 366454 Page 2 of 2