Failure to Provide Safe and Appropriate Tracheostomy Care
Penalty
Summary
The facility failed to provide tracheostomy care consistent with professional standards of practice for two residents, resulting in an Immediate Jeopardy situation. Both residents had tracheostomies and required specialized respiratory care, including suctioning, oxygen therapy, and regular monitoring. The facility did not maintain current physician orders for tracheostomy care, failed to implement individualized care plans, and did not ensure that staff were competent or properly trained in tracheostomy care. For one resident, the care plan was not updated within 48 hours of admission, and there were no orders for suctioning, tracheostomy care, or enhanced barrier precautions. The other resident's care plan and orders were discontinued and not reinstated upon readmission, leaving the resident without necessary tracheostomy care instructions. Observations revealed that essential emergency supplies, such as an Ambu bag, obturator, and appropriately sized inner cannulas, were not available at the bedside. Suction equipment was improperly stored, and expired supplies were found in residents' rooms. Staff interviews confirmed a lack of training and competency in tracheostomy care, including emergency procedures, suctioning, and obtaining tracheostomy cultures. One LPN admitted to not receiving any training on tracheostomy care and was unaware of emergency protocols or how to obtain a tracheostomy culture. Additionally, staff failed to follow physician orders for oxygen therapy and did not notify the physician when changes in oxygen demand occurred. Residents reported that staff did not know how to care for tracheostomies, and one resident experienced a complete tracheostomy obstruction, requiring hospital transfer and intervention. Documentation and monitoring were inconsistent, with care plans lacking details on the frequency of tracheostomy care and the size of inner cannulas. The facility assessment did not include tracheostomy care, and staff files lacked evidence of education or competency in this area. These failures led to significant respiratory and emotional distress for the residents involved.