Failure to Update Facility Assessment for Laryngectomy Tube Care Needs
Penalty
Summary
The facility failed to update its Facility Assessment following the admission of a resident with a laryngectomy tube, despite this representing a change in the resident population not previously identified in the assessment. The resident was admitted with diagnoses including dementia and a laryngectomy tube, requiring specialized care and equipment for airway management, particularly in the event of cardiopulmonary arrest. The hospital discharge summary and nurse practitioner progress note both documented the presence of a laryngectomy tube and the need for full code status. A review of the Facility Assessment, last updated in July 2025, showed that while it included information on residents with respiratory failure and those requiring oxygen therapy, suctioning, tracheostomy care, ventilator or respirator care, and BIPAP/CPAP, it did not specifically identify residents needing laryngectomy tube care. The assessment also lacked documentation of staff training, competencies, or specialized equipment necessary for managing laryngectomy tubes. During interviews, facility leadership acknowledged that the assessment had not been updated to reflect the needs of residents with laryngectomy tubes after the resident's admission.