Failure to Provide and Document Scheduled Tracheostomy Cannula Change
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy did not receive a scheduled tracheostomy outer cannula change as ordered by the physician. The resident, who had diagnoses including head injuries, quadriplegia, and tracheostomy status, had a physician order for the cannula to be changed monthly on a specific day. Review of the medication administration record (MAR) for the relevant month showed that the cannula change was not documented as completed on the scheduled day or at any other time during the month. Interviews with facility staff, including the ADON, DON, and the LVN assigned to the resident on the scheduled day, confirmed that there was no documentation of the procedure being performed. The LVN stated she may have forgotten to document, but acknowledged that if it was not documented, it was not done. The facility's tracheostomy care policy required that tracheostomy tubes be changed as ordered, at least monthly. The DON confirmed that the expected practice was for staff to provide the required tracheostomy care and that all nurses were trained on this procedure.