Improper Positioning During Enteral Feeding
Penalty
Summary
The facility failed to ensure the proper positioning of the head of the bed (HOB) for a resident receiving enteral tube feeding, which is necessary to reduce the risk of aspiration. During an observation, it was noted that the resident was lying flat on their back while the tube feeding was running, contrary to the facility's policy that requires the HOB to be elevated at least 30 degrees during feeding. This oversight was confirmed by a Licensed Vocational Nurse (LVN) who acknowledged that the HOB should be elevated between 30 to 45 degrees to prevent aspiration and potential aspiration pneumonia. The resident involved had a history of gastro-esophageal reflux disease, dysphagia, and a gastrostomy, and was dependent on staff for personal care. The resident's cognitive assessment indicated limited understanding, highlighting their reliance on staff for proper care. The facility's policy on enteral feedings, dated November 2018, clearly outlines the necessity of elevating the HOB to prevent aspiration, yet this protocol was not followed during the observed incident.
Plan Of Correction
How corrective actions will be accomplished for those residents found to have been affected by this deficient practice: On 3/5/25, Licensed Vocational Nurse (LVN) 6 repositioned Resident 57 head of bed between 30-45 degree angle. LVN 6 evaluated Resident 57 for any negative or adverse outcomes. There were no negative or adverse outcomes related to this deficient practice for Resident 57. How do facility will identify other residents, having the potential to be affected by the same deficient practice and what corrective action will be taken: All residents have the potential to be affected by this deficient practice. On 3/5/25, the Director of Nursing (DON) made visual rounds to ensure all residents receiving enteral feeding head of bed were between 30 to 45 degrees. No other residents were affected by this deficient practice. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/20/25, the Director of Nursing in-serviced Nursing Staff, including but not limited to, LVNs and Registered Nurses and on the facility policy and procedure titled, "Enteral Feedings-Safety Precautions," with emphasis on ensuring the safe administration of enteral nutrition and preventing aspiration by elevating the HOB at least 30 degrees during tube feeding and at least one hour after feeding. The DON/designee will conduct rounds daily for 5 days weekly for 2 weeks and monthly thereafter to ensure residents receiving enteral feeding head of beds are at 30 to 45 degree angle. Department Managers will complete weekday rounds to ensure residents receiving enteral feeding head of beds are at 30 to 45 degree angle. How the facility plans to monitor its performance to make sure that solutions are maintained: The Director of Nursing will report to the Quality Assessment and Assurance Committee during its monthly meeting on the status of the compliance for residents receiving enteral feeding head of bed is at 30 to 45 degrees for three months or until compliance is met. What measures will be into place or what systemic changes the facility will make to ensure that the deficient practice is not recur: On 3/20/25, the Director of Nursing in-serviced Nursing Staff, including but not limited to, LVNs and Registered Nurses and on the facility policy and procedure titled, "Enteral Feedings-Safety Precautions," with emphasis on ensuring the safe administration of enteral nutrition and preventing aspiration by elevating the HOB at least 30 degrees during tube feeding and at least one hour after feeding. The DON/designee will conduct rounds daily for 5 days weekly for 2 weeks and monthly thereafter to ensure residents receiving enteral feeding head of beds are at 30 to 45 degree angle. Department Managers will complete weekday rounds to ensure residents receiving enteral feeding head of beds are at 30 to 45 degree angle. The status of the compliance for residents receiving enteral feeding head of bed is at 30 to 45 degrees will be monitored for three months or until compliance is met.