Failure to Ensure Competency in Enteral Feeding Care Leads to Resident Harm
Penalty
Summary
Nurse aides and licensed nurses failed to demonstrate the necessary competencies and skills to safely care for a resident with a feeding tube, as identified through the resident's assessment and care plan. The resident, who had multiple complex medical conditions including gastrostomy status, severe cognitive impairment, hemiplegia, and dysphagia, required her head of bed to be elevated at least 30 degrees during and after enteral feedings to prevent aspiration. Despite these requirements, a CNA was observed lowering the resident to a flat position while the feeding pump was running, contrary to the care plan and facility policy. Video evidence showed that after the resident was laid flat, white fluid began coming from her mouth, consistent with possible aspiration of tube feeding formula. The LPN present did not immediately intervene to stop the feeding pump or reposition the resident, and there was a significant delay in providing suctioning. The LPN was also observed searching for equipment and not demonstrating a sense of urgency, and the feeding pump remained on for an extended period after the resident showed signs of aspiration. The LPN did not perform a thorough assessment, such as checking vital signs or lung sounds, and post-mortem care was initiated before a registered nurse pronounced death, as required by protocol. Interviews with staff revealed inconsistent and incorrect knowledge regarding the care of residents with enteral feedings, including who is authorized to operate feeding pumps and the importance of head-of-bed elevation. Some CNAs believed it was acceptable to lay residents flat or to pause the pump themselves, while others were unaware of the risk of aspiration. The facility's own policies required head-of-bed elevation and nurse oversight of feeding pumps, but these were not followed, resulting in actual harm to the resident.