Improper Head-of-Bed Elevation During Enteral Feeding
Penalty
Summary
The facility failed to ensure proper positioning during enteral feeding for one resident receiving tube feedings. The resident had a gastrostomy tube and a care plan dated 9/22/25 that specified the need for tube feeding with the head of bed (HOB) elevated to 45 degrees during and for thirty minutes after the feeding. Physician orders dated 2/9/2026 directed that enteral nutrition be administered via an enteral pump at a rate of 50 ml/hr every shift. On 3/5/26 at 10:08 AM, during a concurrent interview and observation with the Infection Preventionist, the resident was observed receiving enteral feeding at 50 ml/hr while positioned with the HOB at approximately 20–25 degrees. The Infection Preventionist confirmed the observed HOB angle and stated the resident’s position should be 35 or 45 degrees. In a subsequent interview at 10:21 AM, the DON stated that residents should be positioned at least 30 degrees when enteral feedings are administered and explained that the resident was placed at high risk for aspiration pneumonia if the bed was not at least at a 30-degree angle or greater.
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