Failure to Maintain and Document Emergency Tracheostomy Kit Checks
Penalty
Summary
The facility failed to ensure that the emergency tracheostomy ventilator unit box (e-kit) was properly checked and maintained monthly according to its own policy and procedure. During an observation, the e-kit was found locked without any indication of when it was last checked, and the Respiratory Therapist Supervisor (RTS) was unable to state when the last check occurred or who was responsible for maintaining the equipment inside the e-kit. A review of the e-kit order form revealed it was blank, with no documentation of when it was last opened or checked. The e-kit contained essential emergency supplies such as a tracheostomy cuffed tube, syringes, and normal saline. Interviews with the RTS and the Director of Nursing (DON) confirmed that the e-kit should be checked and maintained regularly to prevent shortages of supplies in emergencies. The facility's policy, reviewed on 3/20/2025, specified that the equipment should be checked monthly by Respiratory Therapy, be operational, locked with an appropriate tag, and have a signed equipment checklist. These requirements were not met, as evidenced by the lack of documentation and uncertainty regarding responsibility for the e-kit’s maintenance.