Failure to Develop Care Plan for Ventilator/Tracheostomy Care
Penalty
Summary
The facility failed to develop a care plan addressing ventilator and tracheostomy care for one resident who was admitted with chronic respiratory failure, obesity, and encephalopathy. The resident required ongoing interventions including oxygen therapy, suctioning, tracheostomy care, and invasive mechanical ventilation. Despite these needs, a review of the resident's care plans revealed that there was no care plan in place specifically for ventilator or tracheostomy care at the time of review. Interviews with the MDS Nurse and the Director of Nursing confirmed that the absence of a ventilator/tracheostomy care plan meant that essential aspects of care, such as monitoring suctioning, stoma management, and ventilator settings, were not formally addressed. The facility's policy required the interdisciplinary team to develop and implement a comprehensive, person-centered care plan for each resident, including measurable objectives and timeframes, but this was not done for the resident in question.