Failure to Maintain Ordered Head-of-Bed Elevation and Tube Feeding Regimen
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident receiving enteral nutrition via a gastrostomy tube (G-tube) had the head of bed (HOB) elevated as ordered and that tube feedings were administered according to physician orders. The resident had diagnoses including diabetes mellitus and dysphagia, a severely impaired BIMS score, required total assistance with ADLs, and was on hospice with a low BMI. The care plan and physician orders directed that the HOB be elevated 30 degrees continuously during enteral feeding and that Glucerna 1.5 be administered at 50 ml/hr with a scheduled daily two-hour “gut rest” period when the feeding was to be stopped. Surveyors observed multiple instances where these orders were not followed. On one day, the resident was found in bed lying flat while the enteral feeding pump was running at 50 ml/hr; the feeding bag label lacked the type of formula. On the following day, the resident was observed with the HOB at 30 degrees but the feeding pump was off and not connected, and later the same morning the resident remained with the HOB at 3 degrees and the tube feeding still off and disconnected. After medications were given, an LPN turned the pump on and connected the G-tube, then positioned the resident on the left side with the HOB at 30 degrees; later that morning, the resident was observed on the right side with the HOB at 10 degrees while the feeding was running at 50 ml/hr. Staff interviews further demonstrated lack of adherence to and understanding of the orders. One LPN did not notice the resident’s bed was flat while the feeding was running until prompted, and she was unsure how high the HOB should be elevated. CNAs gave inconsistent responses about who had provided care and what HOB elevation was required, with one CNA incorrectly stating the HOB should be elevated to 180 degrees. Another LPN reported that the tube feeding had not been turned back on until mid-morning and was unsure when it had been shut off, and initially could not locate the order for the scheduled two-hour morning interruption of feeding, despite the dietitian’s documented recommendation and the presence of the order in the EMR. The facility’s gastrostomy tube care policy did not address HOB elevation for enteral feedings, while the physician order-following policy required licensed staff to follow physician orders.
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