Failure to Follow Physician Orders and Emergency Protocols for Tracheostomy Care
Penalty
Summary
The facility failed to implement a physician's order for the use of a red rubber catheter for suctioning a resident with a tracheostomy, and did not follow its own policy on suctioning procedures. During observation, the resident was suctioned with a plastic transparent suction catheter instead of the ordered red rubber catheter, and the respiratory therapist was unaware of the specific physician order. The care plan coordinator also was not aware of the order, and the resident's care plan was not updated to reflect this requirement. Additionally, the facility did not have a spare tracheostomy tube set—one of the same size and one of a smaller size—readily available at the resident's bedside, as required for emergency situations such as accidental decannulation. Both the DON and respiratory therapists were unable to locate the necessary spare tracheostomy equipment in the resident's room. The facility was also unable to provide a policy on tracheostomy emergency protocols or evidence of nursing competency skills for respiratory care, including tracheostomy care and suctioning. The resident involved had multiple complex medical conditions, including chronic respiratory failure with hypoxia, tracheostomy, and dependence on a ventilator. Observations showed that suctioning was performed for longer than the recommended duration, without providing ventilation between passes, and without proper hand hygiene between glove changes. The facility's own policies on suctioning and care plan review were not followed, contributing to the deficiencies identified.