Failure to Provide Appropriate Tracheostomy Suctioning and Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with a tracheostomy following a laryngectomy, resulting in repeated episodes of respiratory distress and multiple emergency room (ER) visits. The resident had a history of mucous plugs and required frequent suctioning to maintain a patent airway, as documented by both facility and hospital records. Despite clear indications for suctioning in the facility's own policies and recommendations from medical specialists, the facility did not ensure that staff performed tracheal/stoma suctioning when needed. There was no suctioning equipment at the resident's bedside, and staff were not trained or prepared to perform suctioning beyond superficial or oral cavity suctioning. The resident's medical record showed several ER visits due to respiratory distress, with documentation from EMS and ER staff indicating that mucous plugs were removed during these visits, and that the care provided in the ER was within the scope of practice for facility nursing staff. Facility staff interviews revealed a lack of understanding and training regarding tracheostomy care and suctioning, with staff stating they did not perform deep suctioning and did not consider suctioning part of trach care. The resident was unable to self-suction and expressed anxiety about waiting for emergency services when experiencing respiratory distress. There was also a lack of documentation and education provided to the resident regarding prevention of mucous plugs and the importance of humidification. Physician orders for suctioning were discontinued for a period without documented rationale, and there was no evidence of suctioning being performed or documented by facility staff during critical periods. The facility's inaction and lack of appropriate interventions, including failure to provide necessary equipment and staff training, led to repeated episodes of respiratory compromise for the resident. The surveyor found that the facility did not follow professional standards of practice for tracheostomy care, resulting in a finding of Immediate Jeopardy.