Failure to Document Unplanned Tracheostomy Decannulations in EHR
Penalty
Summary
The facility failed to ensure proper documentation in the electronic health record (EHR) for two unplanned decannulations of a resident's tracheostomy tube. On two separate occasions, the resident experienced unplanned decannulations while being cared for by certified nurse aides, with both incidents being witnessed and reported in facility incident reports. In both cases, the tracheostomy tube was reinserted without difficulty, and the resident did not show signs of distress or decreased oxygen saturation. However, a review of the resident's EHR revealed that there were no progress notes written by a nurse or respiratory therapist regarding these unplanned decannulations, despite the facility's policy requiring nursing staff to document care provided and changes in the resident's condition in the medical record. Interviews with staff, including the respiratory therapist and the director of nursing (DON), confirmed that the expectation was for the nurse who responded to the incident to document the event in the EHR. The respiratory therapist involved in the incident stated he did not believe it was expected of him to chart the change in the EHR. The DON confirmed that the nurse should have documented the incident. The facility's documentation policy, provided by the DON, specifies that nursing staff are required to document care and changes in the resident's condition in the medical record, including through progress notes.