Failure to Maintain Required Tracheostomy Supplies at Bedside
Penalty
Summary
The facility failed to ensure that appropriate tracheostomy (trach) supplies were available for a resident in accordance with the care plan and facility policy. Medical record review showed that the resident had significant medical conditions, including anoxic brain damage, epilepsy, chronic obstructive pulmonary disease, and congestive heart failure, and was dependent on staff for all activities of daily living. The care plan required an extra trach tube and obturator to be kept at the bedside, and physician orders specified daily trach care and regular changes of the inner cannula. However, during observation and staff interviews, it was confirmed that there was not an extra trach tube available at the bedside if the current trach became dislodged. Further interviews revealed that the facility did not always have the necessary trach supplies for the resident. When a replacement trach was brought to the bedside by a unit manager, it was found to be a cuffed trach, which did not match the resident's needs and was not ordered by the physician. Review of the facility's tracheostomy care policy confirmed that a replacement trach tube must be available at the bedside at all times, indicating non-compliance with both the care plan and facility policy.