Failure to Maintain Required Head of Bed Elevation During Tube Feeding
Penalty
Summary
A deficiency occurred when the facility failed to follow physician orders and facility policy regarding the elevation of the head of bed (HOB) for a resident with a gastrostomy tube (G-tube) during enteral feeding. The resident, who had diagnoses including dysphagia and paralytic syndrome, was readmitted with a G-tube and had a care plan and physician orders specifying that the HOB should be elevated between 30 to 45 degrees during and for 30 minutes after tube feedings. During observation, the resident was found receiving continuous tube feeding with the HOB elevated to only 15-20 degrees, contrary to the required elevation. The resident was unable to adjust the bed due to paralysis, and the licensed nurse confirmed the HOB was not at the required angle at the time of observation. Further review of the resident's medical history indicated previous treatment for aspiration pneumonia and a diagnosis of silent aspiration pneumonia upon readmission. Interviews with nursing staff and administration confirmed awareness of the physician's order and the facility's policy, which required HOB elevation to prevent aspiration. The facility's policy also specified the need for HOB elevation during and after tube feedings. Despite these directives, the required positioning was not maintained, resulting in noncompliance with physician orders and facility policy for safe enteral feeding practices.