Deficiency in Tracheostomy Care Documentation
Penalty
Summary
The facility failed to adhere to professional standards for tracheostomy care by not ensuring physician orders included the size of the tracheostomy cannulas for two residents. Resident #87, who had a tracheostomy due to respiratory failure and other medical conditions, did not have physician orders specifying the size of the inner and outer cannula. During an observation, it was noted that the resident's tracheostomy was clean, but the absence of specific orders was confirmed by the Unit Manager, who could not explain the oversight. The Regional Respiratory Therapist emphasized that it is a professional standard to have such orders, including the manufacturer's details, as sizes may vary. Similarly, Resident #38, who also had a tracheostomy, did not have the size of the tracheostomy specified in the physician orders. The resident reported inconsistent tracheostomy care, and during an observation, an LPN replaced the inner cannula with a size 6 Shiley, knowing the size from familiarity rather than documented orders. The Clinical Regional Consultant confirmed that the size should be part of the physician orders and acknowledged that changes were being made to clarify the orders for this resident.
Plan Of Correction
Element 1: Resident #38 and 87 physician orders reviewed and updated to reflect correct trach orders, including sizing. Element 2: Residents with trachs are like residents. No other residents in the facility have a trach. Element 3: The Trach Policy has been reviewed by the NHA and DON and deemed appropriate. The facility-licensed nursing staff have been re-educated on the Trach care policy, and appropriate orders are required. During daily clinical stand-up, nurse managers will ensure orders are in place for Trach. Element 4: Residents who have a Trach will have their orders reviewed weekly for 4 weeks to ensure the orders are correct and match the trach currently being used for each resident. Audits will then be completed monthly for 3 months, or until substantial compliance is obtained or discontinued by the QAPI team. Results will be reviewed monthly by the QAPI Committee. The Administrator is responsible for maintaining compliance.