Failure to Prevent Tracheostomy Self-Decannulation and Inadequate Staff Training
Penalty
Summary
The facility failed to assess, monitor, and provide necessary interventions to prevent self-decannulation for a resident with a known history of removing her own tracheostomy tube. Despite documentation from the resident's infectious disease physician and staff interviews indicating a prior history of self-decannulation, the resident's care plan did not include any interventions to prevent further incidents. The resident exhibited behaviors of pulling on her tracheostomy tube, G-tube, and colostomy bag, which were observed by multiple staff members and therapy personnel, but these behaviors were not consistently documented or communicated to the physician for further evaluation or intervention. On two separate occasions, the resident self-decannulated her tracheostomy tube while in the facility. After the first incident, the resident was transferred to the emergency room for tracheostomy tube replacement and subsequently readmitted to the facility. However, no new interventions were added to her care plan to address the risk of repeated self-decannulation. Staff continued to observe the resident pulling on her medical devices, but there was no evidence of increased monitoring, behavioral interventions, or medication review to address potential agitation or restlessness. Additionally, staff interviews revealed a lack of awareness regarding the resident's history of self-decannulation and the absence of specific interventions to prevent recurrence. The facility also failed to ensure that nursing staff were adequately trained in emergency tracheostomy recannulation. Multiple nurses and CNAs reported not having received training on reinserting a tracheostomy tube and expressed discomfort or lack of competence in managing such emergencies. The facility's tracheostomy care policy did not address emergency reinsertion procedures, and staff were unclear about the availability of necessary supplies or their roles in such situations. This lack of training and preparedness contributed to delays in appropriate emergency response when the resident self-decannulated her tracheostomy tube, ultimately resulting in her transfer to the hospital, where she experienced complications and subsequently died.