Failure to Maintain Required Head of Bed Elevation During Tube Feeding
Penalty
Summary
Facility staff failed to ensure that a resident receiving continuous tube feeding had the head of bed (HOB) elevated to at least 30 degrees as required by physician orders and facility policy. The resident, who had an anoxic brain injury, was ventilator dependent, and required total assistance with all activities of daily living, had a physician order and care plan specifying that the HOB should be elevated no less than 30 degrees during tube feeding. Multiple observations over several days showed the resident lying in bed with the tube feeding running and the HOB elevated only to 15 degrees according to the bed's gauge. Further measurement with a cell phone app confirmed that when the bed gauge read 15, the actual angle was only 18 degrees, which is below the required elevation. The facility's policy on continuous tube feeding also directed staff to elevate the HOB to 30-45 degrees unless contraindicated. Interviews with staff confirmed the HOB was not elevated to the required degree during tube feeding, resulting in noncompliance with both physician orders and facility policy.