Failure to Maintain Proper Head of Bed Elevation During Tube Feeding
Penalty
Summary
A deficiency occurred when a treatment nurse placed a resident with a gastrostomy tube (G-tube) in a flat position while the enteral feeding pump was still running. The facility's policy and the resident's physician orders required the head of bed (HOB) to be elevated 30-45 degrees during tube feedings, and the resident's care plan specified the HOB should be elevated 45 degrees during and for thirty minutes after tube feeding. Despite these directives, the nurse lowered the resident's HOB to a flat position and turned the resident on her side to perform a brief change and wound dressing change, without stopping the enteral feeding pump. The resident involved had a medical history including stroke, myotonic muscular dystrophy, respiratory failure, dysphagia, and gastro-esophageal reflux disease, all of which increase the importance of proper tube feeding management. The nurse confirmed during an interview that the feeding pump had not been turned off while the resident was laid flat and acknowledged that it should have been. The DON also stated that tube feeding should be turned off when a resident is laid down for care.