Failure to Pause Enteral Feeding Pump During Bed Positioning
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding via a feeding tube was provided with appropriate care to prevent complications. Specifically, staff did not pause the resident's feeding pump when the head of the bed was lowered during incontinence care, despite the resident being completely dependent on staff for activities of daily living and having a history of stroke with impaired swallowing and speech. Observations confirmed that the feeding pump continued to infuse while the resident's head was lowered, contrary to established safe practices. Interviews with staff revealed that they were aware of the need to have a nurse pause the feeding pump before lowering the head of the bed, as not doing so could lead to aspiration. However, the responsible CNA admitted to not pausing the pump during care, citing being busy and the delay in waiting for a nurse. The facility's policy on gastrostomy tubes did not address the need to pause the pump when the bed was not elevated, and the deficiency was identified through direct observation, interviews, and record review.