Failure to Implement and Communicate Tracheostomy Restraint Orders Leads to Resident Death
Penalty
Summary
The facility failed to implement ordered respiratory care interventions for a resident with a tracheostomy, specifically neglecting to ensure the application and monitoring of hand mitten restraints as required by the care plan and physician orders. The resident had a documented history of pulling at her tracheostomy tube, and the care plan included the use of mittens to prevent self-decannulation. Multiple staff members, including the respiratory therapist and nursing supervisor, confirmed that the resident was supposed to have mittens applied at all times, but observations and interviews revealed that the mittens were not in place during the relevant shift. The agency nurse assigned to the resident was unaware of the mitten order and did not receive a proper handoff or information about the restraint requirement, and the facility's electronic medical records were inaccessible at the time, further impeding communication. The incident culminated when the resident was found unresponsive with her tracheostomy tube removed, and she was later pronounced deceased by paramedics. Staff interviews indicated that there was no visible evidence of the mittens being applied during the shift, and both the nurse and CNA assigned to the resident were not informed about the restraint order. The respiratory therapist reported that he had reminded the nurse about the need for mittens, but was unsure if any action was taken. Additionally, there was no documented incident report or completed progress note for the event, and the care plan binder at the nurse station was found to be incomplete. The resident's medical history included aphasia following cerebral infarction, acute respiratory failure with hypercapnia, tracheostomy status, and dependence on supplemental oxygen. The resident had previously attempted to remove her tracheostomy tube multiple times, and her daughter had requested the use of restraints, which was eventually ordered and consented to. Despite these clear directives, the facility failed to ensure that the required interventions were consistently implemented and communicated among staff, directly leading to the resident's self-decannulation and subsequent death.