Failure to Maintain Head-of-Bed Elevation During Enteral Feeding
Penalty
Summary
A deficiency occurred when a resident receiving enteral feeding via a gastrostomy tube was observed lying flat in bed while the feeding pump was running. The resident's care plan and physician orders specifically required the head of the bed to be elevated between 30 to 45 degrees during tube feeding and for at least 30 minutes afterward to prevent aspiration. Despite these documented requirements, the resident was found with the bed flat and the feeding pump actively delivering nutrition. Interviews with staff, including a CNA and an LVN, revealed that neither was aware of who had lowered the bed, and both stated they were trained to keep the head of the bed elevated during tube feeding. The staff also confirmed that the risk of aspiration was well known, and the facility's policy required the head of the bed to be elevated during feedings. The resident's family reported that on multiple occasions, they found the bed flat during visits and had to request staff to raise it, indicating a recurring issue. Further interviews with facility leadership, including the DON and ADM, confirmed the expectation that the head of the bed should be elevated during tube feedings. The ADM acknowledged that the resident had a tendency to lay the bed flat and that this behavior was known among staff but had not been specifically care planned. The facility's policy and staff statements consistently supported the need for bed elevation during enteral feeding, but this was not consistently implemented for the resident in question.