Failure to Ensure Competent Tracheostomy Stoma Care and Documentation
Penalty
Summary
Nursing staff failed to ensure appropriate competencies and skills in caring for a resident with a tracheostomy stoma. The resident, who had a history of depression, schizoaffective disorder, diabetes, chronic cough, and an old tracheostomy, was admitted with severe cognitive impairment. The care plan indicated that the neck stoma dressing should be changed per treatment order. However, review of the resident's physician orders revealed there was no active wound care order for the tracheostomy stoma, and the order had been removed from the active orders and electronic treatment administration record in late February. Despite the absence of an active order, observations showed the resident had a dressing over the anterior throat, and interviews confirmed that staff were changing the stoma dressing daily. There was no documentation in the electronic medical record of the tracheostomy stoma care being performed. The respiratory therapist acknowledged providing the care but confirmed that she failed to document the treatments. This lack of orders and documentation demonstrated a failure to ensure staff had the necessary competencies and skills to meet the resident's needs.