Failure to Elevate Head of Bed During Tube Feeding
Penalty
Summary
Facility staff failed to maintain the head of bed at the required 30-45 degree elevation while a resident's tube feeding was infusing. During an observation, the resident was found in a flat position in bed with tube feeding of Nepro 1.8 Cal infusing at 40 mL per hour via feeding pump. Certified Nursing Assistants (CNAs) present during care stated that they believed it was acceptable for the resident to remain flat during tube feeding unless the resident was being turned side to side. The Director of Nursing (DON) later clarified that the head of bed should be elevated during tube feeding to prevent vomiting or aspiration. Review of the resident's physician orders and facility policy confirmed that the head of bed should be elevated to 30-45 degrees during tube feeding unless otherwise ordered.