Failure to Ensure Resident Competency in Respiratory Care
Penalty
Summary
The facility failed to ensure the competency of a resident in performing respiratory care, specifically in changing her tracheostomy inner cannula. Resident #58, who was admitted with diagnoses including Respiratory Failure and Tracheostomy Status, was observed to change her own inner cannula without recent documented competency verification. The resident, who is cognitively intact, reported changing her inner cannula up to three times a day, despite instructions to change it only twice daily. The facility's respiratory therapist confirmed that the resident's competency was last assessed over a year ago, and no current documentation of competency was found in the Electronic Health Record (EHR). The surveyor's investigation revealed that the facility could not locate the competency documentation, as it was reportedly on paper with a previous company. The Regional Nurse Consultant acknowledged the absence of the competency record in the EHR. Additionally, the resident's EHR indicated that she was running out of inner cannulas due to frequent changes, and the facility had doubled her order to prevent shortages. The resident was re-educated on the inner cannula change process only after the surveyor's intervention.
Plan Of Correction
Boca Circle Rehabilitation Center failed to ensure the residents competency when performing care. Actions Taken: 1) Resident #58 was evaluated by the on & and competency and education was completed and uploaded into the electronic medical record. Staff P. was provided education on by the Regional on ensuring documented education and competency is documented for residents that perform self-care. Others Identified: 2) Full house was conducted by the DON/Designee on to ensure residents with that perform their own care have a competency completed. No concerns noted. Measures Taken: 3) Nursing Staff were in serviced on ensuring residents with who perform their own care are assessed for competency starting on by DON/Designee. Newly hired staff and nursing staff will receive this education during general orientation. Ongoing Monitoring: 4) The Director of Nursing/Designee will conduct weekly audits to verify that residents with that care have perform their own care, have a competency completed weekly x 4 weeks, and then every 2 weeks x 2 months. Audit results will be reviewed in Center QAPI meeting until substantial compliance is met.