Failure to Elevate Head of Bed During Tube Feeding
Penalty
Summary
A deficiency occurred when a resident with a Percutaneous Endoscopic Gastrostomy (PEG) tube was observed receiving enteral feeding while lying flat in bed, contrary to physician orders and facility policy. The facility's policy and the resident's care plan both required the head of the bed to be elevated 30-45 degrees during tube feeding and for one hour after feeding. The resident, who had a history of traumatic brain injury and was rarely or never understood, was found supine with the feeding pump infusing, and the head of the bed was not elevated as required. Record review confirmed that the physician's orders specified continuous enteral feeding with the head of bed elevated, and this was also documented in the care plan. During the observation, facility leadership, including the DON and Administrator, acknowledged that the resident was not positioned correctly during the feeding process. The failure to elevate the head of the bed during tube feeding was directly observed and confirmed by staff interviews.