Failure to Provide Required Respiratory Care Equipment for Resident with Tracheostomy
Penalty
Summary
A resident with a history of acute respiratory failure, tracheostomy, muscle weakness, dysphagia, and cognitive communication deficit was not provided with necessary respiratory care equipment as required by professional standards and facility policy. Observations revealed that the resident, who had a capped tracheostomy tube, did not have a replacement trach, suction catheters, a sterile suctioning kit, or a manual resuscitation bag at the bedside. The resident's care plan and most recent MDS assessment did not reflect the need for respiratory care, and physician orders lacked specification of trach size. Interviews with the Regional Nurse Consultant and an RN confirmed that essential emergency tracheostomy equipment should be kept at the bedside for any resident with a trach, regardless of whether the trach is capped. Facility policy also required the presence of specific emergency tracheostomy supplies at the bedside. The absence of these items constituted a failure to provide safe and appropriate respiratory care for the resident in accordance with professional standards, the care plan, and physician orders.