Failure to Maintain Proper Bed Elevation During Enteral Feeding
Penalty
Summary
A deficiency occurred when a resident receiving enteral nutrition via gastrostomy tube was not maintained with the head of the bed elevated to the required 30-45 degrees during feeding, as ordered by the physician and outlined in facility policy. The resident, who had diagnoses including gastrostomy status, dementia, and gastro-esophageal reflux disease, was observed with the bed elevated to only approximately 20 degrees while receiving tube feeding. The order summary specifically required the head of bed to be elevated during and for one hour after feeding. During staff rounds, an LVN did not adjust the bed elevation while the feeding was ongoing and acknowledged that the bed positioning was not acceptable. The DON confirmed that all residents on tube feedings should have the head of bed elevated to 45 degrees to prevent complications. Facility policy also required head of bed elevation to 30-45 degrees during feeding unless medically contraindicated. The failure to follow these orders and policies led to the deficiency.