Failure to Maintain Emergency Tracheostomy Kit at Bedside
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy did not have an emergency tracheostomy kit, including a bag valve mask and the next lower size trach tube, readily available at the bedside as required by facility policy and the resident's care plan. The resident, a female with a history of seizure disorder, respiratory failure, tracheostomy status, and diabetes, was totally dependent on staff for activities of daily living and was rarely or never understood. Her care plan specifically directed that an extra trach tube be kept at the bedside and that staff monitor for signs of respiratory distress. During observation of tracheostomy care, it was noted that there was no emergency trach kit at the resident's bedside. The nurse providing care confirmed that the kit, which should include a bag valve mask and the next lower size trach tube, was not easily accessible due to disorganization of supplies. The nurse also stated she had not seen the emergency kit in the resident's room during her four weeks of employment and acknowledged it was her responsibility, along with others, to ensure the kit was present and accessible each shift. Interviews with the ADON and DON confirmed that facility policy required an emergency trach kit and the next lower size trach tube to be easily accessible in the rooms of residents with tracheostomy status. Both leaders recalled the kit being present earlier but believed it may have been discarded after falling on the floor during room adjustments. They agreed it was the responsibility of nursing staff and administration to check for these items daily and to report any missing supplies. Review of the facility's policy further confirmed the requirement for these emergency supplies to always be present at the bedside.