Failure to Develop Baseline Care Plan for Tracheostomy and Seizure Precautions
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a baseline care plan to address the immediate needs of a resident who was admitted with a tracheostomy and a history of epilepsy. The facility's policy requires the interdisciplinary team to review practitioner orders and establish a baseline care plan to meet immediate care needs, including those specified in physician orders. Review of the resident's clinical record showed that physician orders were in place for seizure precautions and specific tracheostomy care, including site assessment, suctioning, inner cannula changes, and use of a trach collar. Nursing documentation confirmed that tracheostomy care and seizure-related interventions were performed. However, there was no evidence in the resident's care plan of documented goals or interventions related to tracheostomy care or seizure precautions, as required by facility policy. This finding was confirmed with the DON and Administrator.