Failure to Elevate Head of Bed During Enteral Feeding
Penalty
Summary
The facility failed to provide appropriate care and services to prevent potential complications associated with tube feedings for a resident receiving enteral feeding. The facility's policy on enteral feedings required that the head of the bed be elevated at least 30 degrees during feeding and for a specified time afterward to prevent aspiration. However, during an observation, it was noted that the resident's head of the bed was not elevated while the enteral tube feeding was actively infusing, contrary to the care plan and physician's orders. The resident involved had a medical history of dysphagia and functional quadriplegia, necessitating the use of a PEG tube for nutrition. Despite clear physician orders and care plan interventions to maintain the head of the bed elevation during and after feeding, the resident was found lying flat on their back during an active feeding session. This oversight was confirmed by both a licensed practical nurse and the Director of Nursing, indicating a lapse in adherence to the facility's policy and physician directives, potentially compromising the resident's safety.