Failure to Follow Feeding Tube Protocols and Positioning Requirements
Penalty
Summary
Staff failed to follow facility protocols and professional standards regarding feeding tube care for a resident with multiple complex medical conditions, including Parkinson's disease, stroke, pneumonia due to aspiration, dysphagia, malnutrition, larynx cancer, reflux, and gastrostomy. The resident required full staff assistance for all tube feeding management and care. During observation, a registered nurse administered medications via the gastrostomy tube without first checking tube placement, as required by facility policy. When asked about placement verification, the nurse stated that placement is usually checked by auscultating air injected into the tube, but admitted to not performing this check prior to medication administration that morning. Further observations revealed that the nurse used auscultation to check tube placement before administering tube feeding, despite current guidelines and facility policy stating that auscultation is no longer recommended for this purpose. Additionally, the resident's head-of-bed was observed to be at a 20-degree angle during tube feeding administration, which is below the facility's required minimum of 30 degrees to prevent aspiration. The head-of-bed was only elevated to the appropriate angle after the surveyor intervened. The Director of Nursing confirmed that the facility's expectation is to maintain a minimum 30-degree elevation and to verify tube placement prior to any administration through the tube, without using air injection for placement verification.