Failure to Elevate Head of Bed During Enteral Feedings
Penalty
Summary
Two residents with gastrostomy tubes (GT) were not provided appropriate care during enteral feedings, as staff failed to elevate the head of the bed (HOB) to the required angle. For one resident with diagnoses including respiratory failure, dysphagia, and severe cognitive impairment, physician orders and the care plan specified that the HOB should be elevated 30-45 degrees during and after tube feedings. However, during observation, this resident was found receiving tube feeding with the HOB at approximately 15 degrees. A registered nurse confirmed that the HOB was too low and did not meet the required elevation. Similarly, another resident with Parkinson's disease, respiratory failure, dysphagia, and severe cognitive impairment was observed receiving tube feeding while lying on their side with the HOB at less than 30 degrees, nearly flat. The registered nurse confirmed the HOB was only about 20 degrees and acknowledged it should be higher during tube feeding. The facility's policy also required the HOB to be elevated at least 30 degrees during and after feedings. These observations demonstrated a failure to follow physician orders and facility policy for safe enteral feeding practices.