Failure to Ensure Proper Placement of Tracheostomy Mask for Oxygen Therapy
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy and chronic respiratory failure did not receive proper respiratory care as ordered by the physician. During an observation, the resident was found asleep in bed with the tracheostomy mask positioned on the side of the neck rather than directly over the stoma, and the trach tie was slightly loose. The oxygen was set at 2L/min, but the mask was not delivering oxygen as intended because it was not properly placed. The respiratory therapist confirmed that the mask should have been directly on the stoma to ensure proper oxygenation. Record review showed that the resident was dependent to partially dependent for activities of daily living and required ongoing respiratory treatments, including oxygen therapy and tracheostomy care. The physician's orders specified the use of a T-mask with humidification and titration of oxygen to maintain adequate saturation levels. The facility's policy required routine tracheostomy care to prevent airway obstruction and impaired ventilation. Staff interviews confirmed that proper placement of the trach mask is essential for effective oxygen delivery, and failure to do so could result in the resident not receiving the ordered therapy.