Failure to Provide Proper Laryngectomy Care and Airway Management
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with a laryngectomy, resulting in improper airway management. The resident, who was cognitively impaired and required supervision with hygiene and other activities, had a history of laryngectomy, tracheostomy, and related complications. Observations revealed that the resident's laryngectomy tube was found out of place and the resident reinserted it himself. Documentation and care records indicated inconsistencies, such as staff documenting that they performed stoma care even when the resident did it himself, and a lack of accurate assessment of the resident's ability to perform self-care. Physician orders specified that staff should monitor the tube and stoma site every shift, cleanse the area, and reinsert the tube as needed, with specific instructions for emergency situations. However, the clinical record lacked an assessment of the resident's skills for laryngectomy care, and there were no physician orders permitting the resident to perform his own stoma care. The care plan did not reflect the resident's involvement in self-care, and staff were not consistently following the prescribed care procedures. Additionally, the facility did not have the correct equipment for the laryngectomy tube, and staff initially treated the stoma as a tracheostomy rather than a laryngectomy. Interviews with staff and family confirmed that the resident's stoma care was not being performed as ordered, and the facility lacked the necessary supplies for proper care. Staff training was inconsistent, with verbal instructions being relayed rather than formal training or skills assessments specific to laryngectomy care. The facility's policies and documentation did not address the unique needs of laryngectomy care, contributing to the deficiency.