Failure to Maintain Head-of-Bed Elevation During Continuous Tube Feeding
Penalty
Summary
The deficiency involves the facility’s failure to ensure that the head of the bed was elevated for a resident receiving continuous tube feeding. Surveyors observed on multiple occasions that the resident’s bed was flat without elevation while tube feeding was ongoing, including observations on four separate dates and times. The resident had diagnoses of severe protein calorie malnutrition and gastro-esophageal reflux disease and had moderate cognitive impairment with a BIMS score of 10. An LPN who had worked at the facility for one week reported never seeing the resident’s head of bed elevated. The resident stated they did not want the head of the bed elevated because they liked to sleep and could not sleep with the bed raised. The ADON stated the resident should have the head of the bed elevated 45 degrees and could aspirate if it was not elevated, and also stated that the resident would put the head of the bed down if it were elevated and had not been educated on the possible complications of not having the head of the bed elevated. This sequence of observations and statements shows that, despite the resident receiving continuous tube feeding and having relevant medical conditions, the facility did not maintain the required head-of-bed elevation and did not provide education to the resident about the complications of refusing elevation, leading to the cited deficiency.
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