Failure to Maintain Head-of-Bed Elevation During Tube Feeding
Penalty
Summary
A deficiency was identified when a resident receiving gastrostomy tube (GT) feeding was observed lying flat in bed while the tube feeding was running. The resident's medical record indicated orders for aspiration precautions, specifically requiring the head of the bed to be elevated at 30 to 45 degrees during GT feeding. During the observation, the head of the bed was only elevated to 10 degrees, contrary to both the physician's order and the facility's policy. The nurse present confirmed that the standard of practice is to maintain the head of the bed at 30 to 45 degrees during tube feeding. The resident involved had a history of GT placement, chronic obstructive pulmonary disease (COPD), and epilepsy, and was assessed as having severely impaired cognitive skills, being totally dependent on staff for care, and unable to make decisions. Facility policy and the resident's orders both required head-of-bed elevation to prevent aspiration during tube feeding, but this was not followed at the time of the surveyor's observation.