Failure to Maintain Head of Bed Elevation During Tube Feeding
Penalty
Summary
A resident with diagnoses including cerebellar ataxia, COPD, severe malnutrition, and a gastrostomy tube (g-tube) was observed receiving tube feeding while lying flat in bed, contrary to physician orders and facility policy. The care plan and physician's order required the head of the bed to be elevated to 45 degrees during and after tube feedings to prevent aspiration, and the facility's aspiration policy directed that the head of bed should be up 30-45 degrees at all times during tube feeding. During observation, a nurse aide from an agency lowered the resident's bed to a flat position while the tube feeding was infusing, and only stopped when prompted by the surveyor. The nurse aide admitted to not having received a facility orientation and was unaware of the specific requirement to keep the head of bed elevated during tube feeding. Interviews with facility staff revealed that agency nurse aides were assumed to be competent and were not provided with formal facility training, relying instead on agency verification and brief unit tours. The LPN on duty acknowledged that she did not specifically instruct the agency nurse aide to pause the tube feeding before lowering the bed. The Director of Nursing Services (DNS) stated that agency staff were expected to follow facility policies, but the facility did not provide formal training for them. The failure to ensure the head of bed was elevated during tube feeding represented a lack of appropriate care to prevent complications for the resident.