Failure to Provide Safe and Appropriate Tracheostomy Care and Emergency Preparedness
Penalty
Summary
The facility failed to provide necessary respiratory care and services consistent with professional standards of practice for a resident with a tracheostomy. Specifically, the required emergent tracheostomy tube equipment, such as an obturator and Ambu bag, was not immediately accessible at the resident's bedside. Observations confirmed that these items were missing from the resident's room, and staff interviews revealed uncertainty about when the equipment was placed at the bedside. Additionally, the facility's policies lacked clear guidance on the required emergency equipment and staff training for respiratory emergencies. Nursing staff did not comprehensively assess or document the resident's tracheostomy care. The resident's medical record and care plan did not include a thorough evaluation of the resident's ability to perform self-care for the tracheostomy or specify the level of staff supervision required. Documentation inconsistencies were noted, with staff charting that tracheostomy care was completed or supervised, despite interviews indicating that the resident was not performing their own care and that staff had not actually completed the care. The care plan lacked resident-specific goals and interventions related to tracheostomy care. Furthermore, nursing staff had not completed the required training or competencies for tracheostomy care and emergency interventions. Interviews with facility leadership and staff confirmed that training and competency assessments had not been conducted for those responsible for the resident's care. The facility's own assessment identified the need for such training, but it was not implemented. These failures were observed in the context of a resident with significant medical needs, including long-term respiratory failure, cerebral palsy, asthma, and obstructive sleep apnea, who required substantial assistance with daily activities and tracheostomy care.