Failure to Maintain Proper Bed Elevation During Tube Feeding
Penalty
Summary
A deficiency occurred when a resident receiving enteral nutrition via a PEG tube was observed lying completely flat in bed while tube feeding was actively infusing at 55 cc per hour. The head of the bed was not elevated to at least 45 degrees as required by the resident's care plan and physician's orders. Staff interviews revealed that the resident frequently adjusted the bed position using the remote control, and the head of the bed had been elevated earlier during medication administration, but was found flat during the observation. The resident involved had a history of stroke, hemiplegia, dysphagia, chronic kidney disease, heart failure, and a cardiac pacemaker, and was not cognitively intact for daily decision making. The care plan specifically directed staff to maintain the head of the bed at a minimum 45-degree elevation during tube feeding. Facility policy also required staff to follow care plan directives regarding resident positioning during enteral feeding. Despite these directives, the required positioning was not maintained at the time of observation.