Failure to Ensure Nurse Competency in Laryngeal Tube Care
Penalty
Summary
The facility failed to ensure that four licensed nurses had the necessary competencies and skill sets to care for a resident with a laryngeal tube. Education record review showed that these nurses did not receive required training or information on the new process for laryngeal tube care. Despite this, medical record review confirmed that these nurses provided care to the resident, who had complex medical needs including surgical aftercare following respiratory surgery, cancer of the supraglottis and lymph nodes, diabetes, dementia, and anxiety. The resident was severely cognitively impaired and required total care, including frequent monitoring and specialized respiratory interventions as outlined in physician orders and the care plan. Documentation revealed that the resident experienced issues such as the tracheostomy cap repeatedly coming off, stoma tenderness and redness, and frequent coughing up of phlegm, all of which required prompt and skilled intervention. The care plan specified the need for regular cleaning, monitoring for infection, and suctioning as needed. During an interview, the Assistant Director of Nursing acknowledged that she could not confirm staff competency in laryngeal tube care if they had not received the necessary education prior to their shifts.