Failure to Maintain Required Head of Bed Elevation During G-Tube Feedings
Penalty
Summary
The facility failed to ensure that the head of bed (HOB) was properly elevated for five residents receiving gastrostomy tube (G-tube) feedings. During multiple observations, residents were found lying in bed with the HOB elevated to levels ranging from 18 to 27 degrees, which was below the required 35 degrees as specified in their physician orders and care plans. Nursing staff, including registered nurses, a licensed vocational nurse, and the director of nursing, acknowledged during interviews that the HOB should have been elevated to at least 30 or 35 degrees during tube feedings, in accordance with both physician orders and facility policy. Record reviews for each resident confirmed active orders and care plans specifying the required HOB elevation during tube feedings. The facility's policy also directed staff to elevate the HOB to 35-45 degrees during and for at least one hour after feedings. Despite these clear instructions, staff did not maintain the required HOB elevation during observations, resulting in noncompliance with physician orders, care plans, and facility policy for the care of residents with feeding tubes.