Failure to Maintain Head of Bed Elevation During Tube Feeding
Penalty
Summary
Staff failed to follow standard practice for gastrostomy tube care for a resident with severe cognitive impairment, quadriplegia, and multiple medical diagnoses, including a history of recurrent pneumonia and sepsis. The resident was ordered to receive Jevity 1.5 tube feeding at 65 ml per hour for 22 hours daily and was care planned as NPO, with instructions to keep the head of bed (HOB) elevated to 45 degrees during and for thirty minutes after tube feeding to prevent aspiration. Facility policy required the HOB to be elevated at least 30-45 degrees during tube feeding and for at least one hour after. On observation, the resident was found lying flat in bed while tube feeding was infusing, contrary to care plan and facility policy. Staff interviews confirmed that the HOB should have been elevated to at least 30 degrees during tube feeding. The failure to maintain the required HOB elevation was acknowledged by both nursing assistants and licensed staff, and the facility's policy was consistent with this standard of care.