Lack of Staff Competency for Laryngectomy Tube Care
Penalty
Summary
The facility failed to ensure that nursing staff possessed the necessary competencies to care for a resident with a laryngectomy tube. Specifically, the facility's assessment did not identify any residents requiring laryngectomy tube care, nor did it indicate that staff had received training or competency evaluations for this type of care. Multiple nurses, including those regularly assigned to the resident, were unable to distinguish between a tracheostomy and a laryngectomy, and reported not receiving any specific training or competency assessment related to laryngectomy tube care. The Assistant Director of Nurses, who also served as the Staff Development Coordinator, confirmed that while tracheostomy care training had been provided, no such training or competency assessment existed for laryngectomy care, and there was no facility policy addressing this need. The resident in question was admitted with a laryngectomy tube and Alzheimer's Dementia. Interviews with nursing staff and the resident's physician revealed a lack of awareness and understanding regarding the resident's specific airway needs. The physician was unaware of the difference in stoma type and expected that staff would have received appropriate training and that necessary equipment would be available. The absence of staff training, competency assessment, and facility policy for laryngectomy care directly contributed to the deficiency identified during the survey.