Failure to Provide Required Tracheostomy Care and Documentation
Penalty
Summary
The facility failed to provide necessary respiratory care consistent with professional standards of practice for a resident with a tracheostomy. Facility policy required daily tracheostomy care and as-needed dressing changes, including removal of the drain/dressing sponge and cleaning around the stoma site and trach plate. Review of the resident's care plan indicated interventions such as ensuring trach ties were secured, suctioning as needed, monitoring for changes in status, and using universal precautions. However, the resident reported that tracheostomy care was not performed daily by nursing staff, and observations confirmed the presence of a tracheostomy with a cap in use. Further review of the clinical record revealed a physician order for a #8 shiley cuffless tracheostomy tube, but observation and staff interview identified the resident was actually using a #6 shiley cuffless tube, indicating a discrepancy in documentation. There was no documented evidence of physician orders or a comprehensive care plan for the daily care of the tracheostomy or for the management of the cap. Staff confirmed the lack of physician orders and documentation for daily tracheostomy care and cap management, constituting a failure to follow resident care policies and nursing service requirements.