F0693

D

Failure to Maintain Head-of-Bed Elevation and Abdominal Binder During Continuous PEG Feeding

Iowa City, Iowa Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain appropriate positioning and use of an abdominal binder for a resident receiving continuous PEG tube feedings. The resident was cognitively impaired, diagnosed with paraplegia, non-Alzheimer’s dementia, and malnutrition, and was dependent on continuous gastric tube feedings to meet nutritional needs. Physician orders specified NPO status, continuous Glucerna 1.2 at 75 mL/hr via PEG tube, and an abdominal binder to be worn at all times, placed on backwards to prevent removal by the resident. On multiple observations, the resident was found in bed with the head of the bed flat while the feeding pump continued to run at 75 mL/hr, and without the ordered abdominal binder in place. The PEG tubing was also observed under tension when the resident self-transferred from wheelchair to bed while the feeding remained attached to a pole fixed to the wheelchair.

Throughout the observation period, nursing staff, including an RN and a CNA, passed by or entered the resident’s room several times without elevating the head of the bed or ensuring the abdominal binder was applied, despite acknowledging in interviews that the head of the bed should be elevated at least 30–45 degrees during continuous tube feeding and that the binder was required to prevent the resident from pulling out the PEG tube. The facility’s policy on care and treatment of feeding tubes stated that feeding tubes would be used in accordance with current clinical standards of practice with interventions to prevent complications, but it did not provide specific direction on head-of-bed positioning while a feeding pump was running. These actions and omissions led to the identified deficiency in providing appropriate care for a resident with a feeding tube.