Failure to Elevate Head of Bed During Enteral Feeding
Penalty
Summary
A deficiency was identified when a resident with a gastrostomy tube was observed lying flat on a mattress on the floor while receiving tube feeding, without any wedges or elevation to the head of the bed. The resident had medical orders requiring the head of the bed to be elevated to 30 degrees every shift, and the care plan specified elevation to 45 degrees during and for thirty minutes after tube feeding. Despite these documented requirements, the resident was found receiving tube feeding at 100 milliliters per hour from a kangaroo pump while lying flat, with no evidence of head-of-bed elevation. Record reviews showed that nursing staff had been signing off on the medication administration record (MAR) indicating the head of the bed was elevated as ordered, including on the day of the observation. Interviews with nursing staff and the DON confirmed that the standard practice was to elevate the head of the bed for residents receiving tube feedings, and that wedges should be used for residents whose mattresses are on the floor. However, the staff were unaware that the resident did not have wedges in place at the time of the observation, and the DON was not aware of the omission until it was brought to her attention. The facility's enteral nutrition policy referenced the need for head-of-bed elevation to reduce aspiration risk, and CDC guidelines recommend elevating the head of the bed to 30-45 degrees for patients at high risk for aspiration, such as those with enteral tubes. Despite these standards and the resident's care plan, the required positioning was not maintained, resulting in a failure to provide appropriate care and services to prevent complications associated with enteral feeding.