Failure to Maintain Required Emergency Tracheostomy Tubes at Bedside
Penalty
Summary
The facility failed to ensure the availability of a reserve emergency tracheostomy tube at the bedside for a resident with a tracheostomy connected to a ventilator. During an observation, it was noted that only one spare tracheostomy tube was present in the resident's room, instead of the required two (one of the same size and one smaller). The respiratory therapist confirmed that two emergency tracheostomy tubes should be kept at the bedside for emergencies, and explained that the missing tube of the same size had been used previously and not replaced. A review of the facility's policy indicated that a tracheostomy tube of appropriate size must be maintained at the bedside for all intubated residents in case of accidental extubation, decannulation, or other emergencies, and that the reserve tube should be replaced immediately after use. The failure to replace the used emergency tracheostomy tube resulted in non-compliance with the facility's policy and created a deficiency in providing safe and appropriate respiratory care for the resident.