Failure to Maintain Required Tracheostomy Equipment at Bedside
Penalty
Summary
Facility staff failed to provide respiratory and tracheostomy care consistent with professional standards for a resident with a tracheostomy. The facility's policy required that a replacement tracheostomy tube be available at the bedside at all times. Clinical record review showed that the resident had a tracheostomy and physician orders for daily and as-needed tracheostomy care, including changing the inner cannula and checking skin integrity around the trach site and neck. The resident's care plan also included interventions such as ensuring trach ties are secured, elevating the head of bed, providing oral care, and suctioning as necessary. The resident was assessed as cognitively impaired. During observations on two separate dates, the resident was noted to have a tracheostomy present. However, when staff were asked to locate the emergency kit and replacement tracheostomy tube, neither could be found at the bedside or at the nurse's station. Both the LPN present and a second LPN were unable to locate the required items. This failure to have the necessary emergency tracheostomy equipment readily available at the bedside was confirmed during a meeting with facility leadership.