The nurse told state inspectors on October 6 that the bottle was already there when she started work at 6:30 AM. She didn't know when someone had hung it or what it contained.
"Although she assumed that it was Glucerna 1.5 as per physician order, she had no way of knowing," inspectors wrote after interviewing the licensed practical nurse at Camp Hill Skilled Nursing and Rehabilitation Center.
The resident, identified only as Resident 8, suffers from acute kidney failure and diabetes. Both conditions require careful monitoring of nutrition and fluid intake. Acute kidney failure represents a sudden and often temporary loss of kidney function, while diabetes affects how the body manages blood sugar.
The physician had ordered Glucerna 1.5, a specialized tube feeding solution, to be administered at 66 milliliters per hour for 22 hours daily starting September 20. The resident's care plan, revised September 18, specifically noted the enteral feeding tube was necessary to meet nutritional needs.
But when inspectors observed the setup at 1:45 PM on October 6, the bottle contained an unidentified beige liquid. No label indicated what solution was inside, who had prepared it, or when it was hung for use.
The nursing home's own administrator acknowledged the problem when inspectors interviewed him 30 minutes later. He told them he would expect tube feeding solutions to be labeled with both the contents and the time and date they were hung.
Yet the facility's policy offered no guidance on this basic safety measure. Inspectors reviewed the nursing home's Enteral Management policy, revised as recently as July 22, and found it "failed to reveal any expectation that tube feeding solution would be labeled with the name of the solution and date/time that the tube feeding was initiated."
The violation represents what federal regulators call a breakdown in fundamental patient safety. Feeding tubes deliver nutrition directly into a patient's digestive system, bypassing normal safeguards like taste and smell that might alert someone to contaminated or incorrect substances.
For Resident 8, the stakes were particularly high. Patients with kidney failure must carefully limit certain nutrients and fluids to avoid overwhelming their compromised organs. Diabetic patients require precise carbohydrate management to control blood sugar levels.
The licensed practical nurse's assumption that the bottle contained the ordered Glucerna 1.5 solution highlighted the dangerous guesswork that unlabeled medical supplies can force on caregivers. Without proper identification, staff cannot verify they're administering the correct nutrition formula, at the right concentration, prepared at the appropriate time.
Federal regulations require nursing homes to ensure feeding tubes are used only when medically necessary and that residents receive appropriate care when tubes are in place. The Camp Hill facility's failure to maintain basic labeling standards undermined both requirements.
Inspectors determined the violation caused minimal harm or potential for actual harm, affecting few residents. But the finding exposed a systemic gap in the facility's safety protocols that could affect any patient receiving tube feedings.
The nursing home administrator's acknowledgment that labeling should be standard practice contrasted sharply with his facility's written policies, which provided no such guidance to staff. This disconnect between leadership expectations and operational procedures left nurses like Employee 1 to navigate critical medical decisions without clear protocols.
State health department regulations require Pennsylvania nursing homes to maintain proper nursing services, including safe medication and nutrition administration. The unlabeled feeding solution violated these standards by creating unnecessary risks for a vulnerable resident with complex medical needs.
The October 6 inspection occurred in response to a complaint, suggesting concerns about the facility's practices had reached state regulators through other channels. Camp Hill Skilled Nursing and Rehabilitation Center must now develop a plan of correction addressing how it will ensure proper labeling of all tube feeding solutions.
For Resident 8, the immediate question remained unanswered: what nutrition solution had been flowing into their feeding tube for an unknown number of hours that October morning, and whether it matched their physician's careful orders for managing kidney failure and diabetes.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Camp Hill Skilled Nursing and Rehabilitation Ctr from 2025-11-20 including all violations, facility responses, and corrective action plans.
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