Failure to Provide Emergency Tracheostomy Equipment
Penalty
Summary
The facility failed to provide emergency equipment for a resident on mechanical ventilation with a tracheostomy, leading to a deficiency in respiratory care. The resident, who had chronic respiratory failure with hypoxia, anoxic brain damage, dysphagia, hypertensive heart disease, and tracheostomy status, was observed without an emergency trach kit at the bedside. The LPN assigned to the resident was unaware of the need for an emergency trach kit and did not know the protocol for emergency situations involving tracheostomy care. The Central Supply staff confirmed it was their responsibility to place the emergency trach kit at the bedside, but it was not present. The Unit Manager and the Director of Nursing acknowledged the importance of having emergency supplies readily available and verified that the facility's policy required such equipment to be at the bedside. However, the facility's training and orientation processes appeared insufficient, as the LPN was not adequately informed about emergency procedures. The facility's policy and procedure for respiratory and tracheostomy care indicated that care should be consistent with professional standards, but the lack of emergency equipment at the bedside demonstrated a failure to adhere to these standards.
Plan Of Correction
A) What corrective action(s) will be accomplished for those residents found to have been affected by this practice? a. An extra tube (emergency kit) was placed at bedside for resident number 22. B) How will you identify other residents having the potential to be affected by the same practice, and what corrective action will be taken? a. The Director of Nursing/designee completed an audit to ensure extra tube kept at bedside (Emergency kit). C) What measures will be put into place or what systemic changes will you take to ensure that the practice does not reoccur? a. The Director of Nursing/designee completed education with licensed Nurses on ensuring we have extra tube kept at bedside (Emergency Kit). D) How will the corrective actions be monitored to ensure the practice will not reoccur; what quality measures will be put into place? a. The Director of Nursing/designee to complete random audit of extra tube stored at bedside (emergency kit) to ensure compliance with federal regulation F695 weekly x 4 weeks then monthly for 2 months or until substantial compliance is achieved. b. Findings will be reported monthly at the QA/Risk management meeting until such time substantial compliance has been determined.