Failure to Provide Tracheostomy Care, Supervision, and Supplies
Penalty
Summary
A resident with a history of cervical disc disorder and traumatic amputation was admitted to the facility with a tracheostomy and was care planned to perform self-care of his tracheostomy site, with staff instructed to observe and ensure supplies were available. The resident was cognitively intact and had physician orders for daily and as-needed tracheostomy care, including changing the inner cannula, performing trach care every shift, suctioning as needed, and changing the tracheostomy tie weekly. Despite these orders and care plan instructions, the resident reported that staff did not check on him during tracheostomy care, and there were no tracheostomy care supplies or suction equipment available in his room as required. During interviews and observations, the resident stated he used non-sterile items such as toilet paper and napkins to clean and support his tracheostomy tube due to a lack of appropriate supplies. He also revealed that his inner cannula had not been changed or cleaned since admission, and possibly for over a year, and that he would clear blockages himself by removing the inner cannula and coughing out mucus. Staff interviews confirmed that nursing staff had not observed or performed tracheostomy care for the resident, and documentation of care was based on the resident's verbal confirmation rather than direct observation or assistance. Further investigation revealed that staff were unaware of the resident's tracheostomy tube size and were unable to promptly locate appropriate supplies in the supply room. The facility was undergoing a transition with no designated treatment nurse, and regular nursing staff were responsible for treatments. Despite care plan instructions and physician orders, there was a lack of supervision, observation, and provision of necessary supplies for the resident's tracheostomy care, resulting in the resident using inadequate materials and not receiving proper care as ordered.