Failure to Obtain Physician's Order for Tracheostomy Care
Penalty
Summary
The facility failed to obtain a physician's order for tracheostomy care and suctioning for a resident with a tracheostomy, leading to inadequate care. The facility's policy required tracheostomy care to be performed at least once per shift, but this was not documented for the resident. The resident was admitted with a tracheostomy, as noted in hospital documentation, but the facility did not have an order for tracheostomy care or suctioning until several days after admission. The deficiency was further highlighted when the resident's daughter was observed performing unsafe suctioning procedures, including using saline and tweezers to remove secretions. The nursing staff intervened and informed the daughter that such procedures were unsafe. It was confirmed by the Director of Nursing that the facility did not obtain the necessary physician's order upon the resident's admission, resulting in a failure to provide the required tracheostomy care and suctioning.
Plan Of Correction
F 695 - Resident 1 has been discharged from the facility. No corrective action can be completed. All residents with a tracheostomy will be reviewed by the Director of Nursing, or designee, to ensure orders are present for both suctioning and tracheostomy care as appropriate. Education to be provided to licensed nursing staff by the Director of Nursing, or designee, on the importance of ensuring appropriate suctioning orders and tracheostomy care orders are present for residents with a tracheostomy. Each new admission of a resident with a tracheostomy will be reviewed by the Director of Nursing, or designee, to ensure appropriate suctioning orders and tracheostomy care orders are present for residents with a tracheostomy. Results of the audits will be reviewed at the monthly QAPI meeting for tracking and trending purposes. The Director of Nursing shall ensure compliance.