Failure to Ensure Safe Positioning and Timely Intervention During Enteral Feeding
Penalty
Summary
A deficiency occurred when a resident with a feeding tube was laid flat by a CNA while the feeding pump was actively running, contrary to the care plan and facility policy that required the head of the bed to be elevated at least 30 degrees during and after enteral feeding. The resident had significant medical conditions, including severe cognitive impairment, dysphagia, gastrostomy status, and chronic respiratory disease, making her particularly vulnerable to complications from improper tube feeding management. Video evidence showed the CNA lowering the bed and the feeding pump remaining on, with no immediate intervention to pause the feeding or reposition the resident. Shortly after being laid flat, the resident began to have a moderate amount of white fluid coming from her mouth, which appeared to be formula. The LPN present did not immediately stop the feeding pump or reposition the resident, and there was a delay in providing suctioning. The LPN was observed searching for suction equipment and did not act with urgency, resulting in a significant delay before suctioning was performed. Throughout this period, the feeding pump continued to run, and the resident was not promptly assessed for vital signs or lung sounds as required by protocol. Interviews with facility staff, including the DON and ADM, confirmed that the actions taken by the CNA and LPN did not follow established protocols for enteral feeding management and aspiration precautions. The staff failed to demonstrate a sense of urgency, did not properly assess the resident after signs of aspiration, and did not document the incident accurately. The incident was identified as Immediate Jeopardy due to the failure to provide appropriate treatment and services to prevent complications of enteral feeding, specifically aspiration.