Health inspection·August 28, 2024

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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who is fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #11) of 11 residents reviewed for quality of care. The facility failed to ensure that Resident #11's enteral feeding formula was properly labeled. This failure put residents at risk of not receiving adequate nutrition by way of enteral feeding. Findings included: Record review of Resident #11's face sheet dated 8/26/24 revealed a [AGE] year-old male who was re-admitted to the facility on [DATE] with diagnoses of gastro-esophageal reflux disease (frequent acid reflux or reflux of nonacidic content from the stomach), protein-calorie malnutrition, and gastronomy status (surgical formation of an opening through the abdominal wall into the stomach). Record review of Resident #11's quarterly MDS assessment dated [DATE] revealed a BIMS score of 09 indicating his cognition was moderately impaired, and had feeding tube. Record review of Resident #11's care plan last reviewed on 06/29/24 revealed a focus area for requires tube feeding related to dysphagia (difficulty swallowing) with interventions of The resident is dependent with tube feeding and water flushes. See MD orders for current feeding orders. Record review of Resident #11's active orders for August 2024 revealed enteral feed order every shift, Peptamen 1.5 60ml/hr with water bolus 25ml/hr. During an observation and interview on 08/26/24 at 3:33 pm, Resident #11 was in bed with head of bed elevated at 30 degrees and on continuous g-tube feeding. Resident #11's g-tube feeding was noted to run at 60ml/hr and with water bolus of 25ml/hr. Resident #11 was alert and oriented to person, place, and event. Resident #11 stated the nurses switch out the feeding at least once a day. Resident #11 stated he had never seen a feeding tube longer than a day. Resident #11 stated when the feeding was empty the machine should start peeping alerting the nurses to hang a new feeding bag. Resident #11 stated he was not sure when the feeding bag was hung that day. During an observation and interview on 08/26/24 at 3:35 pm, the DON looked at Resident #11's feeding bag and stated it was not labeled. The DON stated the feeding bag should have been labeled with the resident's name, date, and time it was hung. The DON stated the nurse administering the feeding Page 1 of 2 676342 676342 08/28/2024 St. Teresa Nursing & Rehab Center 10350 Montana Avenue El Paso, TX 79925

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few was the one responsible for ensuring the feeding bags were labeled when administering to ensure the proper feeding was administered. The DON stated failure to label Resident #11's feeding bag placed him at risk for lack of monitoring to ensure he received his feeding as ordered. The DON stated the nurses received feeding tube training upon hire and as needed. During an interview on 08/26/24 at 3:51 pm, LVN A stated he was the nurse in charge for Resident #11. LVN A stated he had just hung Resident #11's feeding up about 10-15 minutes ago. LVN A stated he was going to label Resident #11's feeding bag but had been pulled aside by another resident. LVN A stated he was aware Resident #11 feeding was not labeled and he should have labeled the feeding bag at the time he had hung up to administer. LVN A stated the failure to label the feeding bag with the name, rate, date, and flow, there was a risk for administering the wrong feeding and lack of monitoring due to not knowing the time the feeding bag was hung to ensure they received the appropriate feeding as ordered. LVN A stated he received feeding tube care training upon hire. During an interview on 8/28/24 at 2:24 pm, the Administrator referred nursing questions to the DON. Review of the gastronomy tube care policy dated 2/13/2007 read in part procedure #11 labeling/datingformula and or feedings should be labeled with at least the date and time the administration began. 676342 Page 2 of 2