Failure to Follow Protocol for Tube Feeding Pump Operation
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) paused a resident's tube feeding pump and lowered the head of the bed (HOB) without notifying a nurse, contrary to facility policy. The resident involved had multiple complex medical conditions, including multiple sclerosis, muscle wasting, dysphagia, Parkinsonism, functional quadriplegia, and required a gastrostomy tube for nutrition. The resident was cognitively impaired, required total assistance for activities of daily living, and was dependent on staff for all care. During observation, the resident was found leaning to one side with the HOB appropriately elevated and the tube feeding pump running. The CNA repositioned the resident, paused the feeding pump, lowered the HOB, and then raised it again before restarting the pump, all without nurse involvement. The CNA stated she believed aides were allowed to pause the pump for care tasks, although she also acknowledged that only nurses were supposed to handle the pump. The CNA did not immediately notify the nurse after the intervention. Interviews with nursing staff and the director of nursing (DON) confirmed that only nurses were permitted to operate the tube feeding pump, and CNAs were expected to call for nurse assistance when care involving the pump was needed. Facility policy and recent in-service training reinforced this expectation, specifying that CNAs should not touch the pump except in emergencies and must notify a nurse for all G-tube related care. The CNA had signed documentation acknowledging this policy, but the incident demonstrated a failure to follow established procedures, resulting in a deficiency related to the care and management of residents with feeding tubes.