Failure to Provide Tracheostomy Training for Staff
Penalty
Summary
The facility failed to implement and maintain an effective tracheostomy training program for staff caring for a resident with a tracheostomy. The resident, admitted with acute respiratory failure and a tracheostomy, was transferred to the hospital after an incident involving improper setup of humidified oxygen tubing and partially filled humidifier water, as documented by EMS. Staff interviews revealed that multiple staff members, including agency LPNs and a CMA, had not received tracheostomy training from the facility. One LPN reported not feeling qualified to care for a resident with a tracheostomy and relied on a CNA for guidance, while another staff member stated only one nurse was assigned to the resident, with no clear backup if that nurse was unavailable. Further, the physician assistant expressed uncertainty about the staff's competency in tracheostomy care, noting inconsistent answers from staff regarding the resident's care. The administrator and director of nursing services were unable to provide documentation showing that staff had been trained to care for residents with tracheostomies. These findings indicate that the facility did not ensure staff were adequately trained or documented as trained to provide appropriate care for a resident with a tracheostomy.