Failure to Develop Comprehensive Care Plan for Tracheostomy Care
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan to address the tracheostomy care needs of a resident. Record review showed that the resident was admitted with multiple diagnoses, including anemia, dysphagia following cerebral infarction, COPD, GERD, and acute kidney failure, and had undergone surgery on the digestive system. Despite these complex medical needs, the resident's care plan did not include any care area or interventions related to tracheostomy or respiratory care. Additionally, physician's orders did not specify tracheostomy size, replacement cannula, suction machine, manual resuscitation bag, or dietary changes. Interviews with facility staff revealed that the MDS coordinator, who was responsible for initiating and updating care plans, acknowledged that the care plan had been revised but did not address tracheostomy care, and was unsure how this omission occurred. The DON confirmed that the interdisciplinary team is responsible for developing individualized care plans and emphasized the importance of updating care plans to communicate residents' needs and ensure proper care. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timeframes, but this was not followed for the resident in question.