Failure to Ensure Proper Positioning During Enteral Feeding Leads to Aspiration
Penalty
Summary
A facility failed to ensure that a resident receiving enteral nutrition was provided with appropriate treatment and services to prevent complications associated with tube feeding. The resident, an elderly male with Alzheimer's disease, severe protein-calorie malnutrition, gastrostomy status, anorexia, and dysphagia, was dependent on staff for all activities of daily living and had significant cognitive and physical impairments. According to the care plan and physician orders, the resident required the head of the bed to be elevated to at least 30 degrees during and after tube feedings to prevent aspiration. On the day of the incident, the resident was observed via video leaning over the left armrest of his Geri-chair for approximately 1 hour and 30 minutes during a tube feeding. Despite a CNA briefly attempting to reposition him, the resident quickly returned to the slumped position and remained there, moaning and grunting, until a nurse later intervened and repositioned him with pillows. The CNA did not check on the resident again due to being the only staff member assigned to the hallway and feeling overwhelmed by staffing shortages. The nurse who later found the resident did not receive any report from the CNA about the improper positioning. Following the incident, the resident's family member, after reviewing the video footage, requested a chest x-ray due to concerns about possible aspiration. The resident was subsequently transferred to the hospital, where aspiration into the airway was confirmed. Interviews with staff revealed that both the CNA and the nurse recognized that improper positioning during tube feeding could result in aspiration, and both cited staffing concerns as a contributing factor to the failure to provide adequate care and monitoring.