Failure to Elevate Head of Bed for Resident with G-Tube
Penalty
Summary
A deficiency occurred when a resident with a gastrostomy tube (g-tube) was observed lying flat in bed, contrary to physician orders and the resident's care plan, which required the head of the bed to be elevated at 30-45 degrees during and after enteral feeding. The resident, who had severe cognitive impairment and dysphagia, was found with a bottle of feeding formula at the bedside and the bed in a flat position. Staff interviews confirmed that the head of the bed should have been elevated to prevent complications, and that the omission was likely due to staff oversight after providing care. The resident's care plan and physician orders specifically directed that the head of the bed be elevated during feeding and for a period afterward, but this intervention was not consistently implemented. Staff acknowledged the importance of this measure and admitted to not always ensuring the bed was properly positioned after care activities. The facility's policy also required appropriate positioning for residents with g-tubes, but this was not followed in this instance.