HospitalInspections.org

Based on document review and interview, it was determined that for 1 of 3 (Pt. #34) patient records reviewed for aspiration precautions (protecting the lungs from aspiration [breathing in any object other than air]), the Hospital failed to ensure that the head of the bed was elevated at a minimum of 45 degrees while administering an enteral tube feeding (liquid nutrients through a tube inserted in the abdomen). This failure increased the potential for aspiration.

Findings include:

1. On 3/27/19, the Hospital's policy titled, "Guidelines for Patients on Enteral Feedings (effective 04/2014) was reviewed. The policy included, "...3. For all patients receiving enteral feedings... Position patient with head elevated at all times during feeding at least... one hour after the feeding..."

2. On 3/27/19, Pt. #34's medical record was reviewed. Pt. #34 was a 53 year old male who was admitted to the Hospital on 3/14/18 with a diagnosis of left basal ganglia hemorrhagic CVA (Cerebral Vascular Accident/stroke). The clinical record contained a physician's order dated, 3/14/18 that included a supplemental enteral tube feeding from 4:00 PM to 8:00 AM. Another physician's order on 3/14/18 at 3:49 PM included, "Precaution - Aspiration... Head of bed at or above 30 degrees at all times, 45 degree minimum HOB [Head of Bed] elevation for feeding when unable to get OOB [out of bed]. Patient may not lay flatter than 30 degrees within 1 hour after feeding." On 3/14/18 at 10:00 PM, the record indicated that Pt. #34 received 240 ml (mililiters) of tube feeding and 300 ml of tube (water) flush at 10:00 PM. E #26 (Registered Nurse assigned to Pt. #34 on 3/14/18) documented at 10:00 PM, "Head of Bed Position ... 30-45 degrees ..." Pt. #34's head of bed was not elevated at a minimum of 45 degree angle during the tube feeding.

3. On 3/29/19, the Hospital's Job Description for Registered Nurses (revised 2014) was reviewed and included, "... Principal Responsibilities... 6. Implementation/Evaluation - Implement interventions consistent with the established plan of care, interdisciplinary treatment plan..."

4. On 3/28/19 at 9:35 AM, an interview with the Clinical Nurse Leader (E #20 ) was conducted. E #20 stated that a patients HOB must be elevated at 45 degrees or higher while eating or receiving tube feedings to decrease the risk of aspiration.

5. On 3/28/19 at 10:30 AM, an interview with Pt. #34's Attending Physician (MD #2). MD #2 stated that it is the aspiration risk protocol to keep a patient's head of bed elevated at 45 degrees or higher while a tube feeding is being administered. MD #2 stated that the head of the bed is elevated at 45 degrees or higher to decrease risk of aspiration.

6. On 3/29/19 at approximately 9:43 AM, a telephone interview was conducted with E #26 (Registered Nurse assigned to Pt. #34 on 3/14/18). E #26 stated, " ...Do not remember (Pt. #34) ... responsibilities include carrying out physician's order ...purpose for 45 degree (head of bed elevation) ... prevents aspiration ... If there's an order for 45 degree (head of bed elevation) ... it has to be 45 degree and above ..."