Failure to Ensure Staff Competency in Safe Tube-Feeding Management
Penalty
Summary
Nursing staff failed to demonstrate the required competencies for safe tube-feeding management for one resident with significant medical needs, including hemiplegia, COPD, dysphagia, and severe cognitive impairment. Facility policy and physician orders required the resident's head of bed to be elevated 30 to 45 degrees during tube feeding and for a period after feeding to prevent complications. However, the resident was observed lying flat in a supine position while actively receiving tube feeding, contrary to both policy and orders. This was confirmed through observation and interviews, with the resident's roommate reporting a delay in staff assistance and advocating on the resident's behalf due to the resident's inability to communicate needs. Interviews with staff revealed that the LPN last saw the resident with the head of bed elevated, but believed a CNA may have repositioned the resident and failed to return the bed to the proper position. The CNA described a process of placing the feeding pump on hold and lowering the bed for care, but had not yet rounded to the resident's room when the deficiency was discovered. The Director of Nursing confirmed that nurses are responsible for tube feeding management and that CNAs are expected to round every two hours, with nonverbal residents under constant supervision. The failure to ensure staff competency in maintaining proper positioning during tube feeding led to the resident receiving feeding while flat, as observed by surveyors.