Failure to Ensure Competent Tracheostomy Care by Qualified Staff
Penalty
Summary
The facility failed to ensure that staff were educated and competent in providing necessary care and services for residents with tracheostomies, as required by each resident's written plan of care. Multiple residents with tracheostomies experienced repeated episodes where staff were unable to perform routine tracheostomy care, such as suctioning, cleaning, and tube changes. In several cases, residents were sent to the hospital for issues that should have been managed within the facility, including removal of mucus plugs, tracheostomy replacement, and management of secretions. Documentation revealed that staff did not perform suctioning when residents exhibited symptoms such as secretions or emesis from the tracheostomy, and there was a lack of documentation of interventions to prevent repeated tracheostomy dislodgement in one resident. One resident was found unresponsive, and staff performed CPR incorrectly by bagging the resident's mouth instead of the tracheostomy, as they were unaware of the correct procedure. Staff interviews confirmed that neither the LPNs nor CNAs had received training on tracheostomy care or emergency response for residents with tracheostomies. The local fire department and paramedics reported frequent calls to the facility for non-emergent tracheostomy issues, such as suctioning and cleaning, which they considered routine care that should be managed by facility staff. In several instances, emergency responders found that the facility lacked necessary equipment, such as suction tips, and that staff were not using available equipment properly. The deficiency was further evidenced by staff statements indicating a lack of formal or routine training on tracheostomy care, with some staff expressing discomfort and lack of knowledge in providing such care. The facility's own documentation and job descriptions required staff to remain current in facility policies and procedures, including specialized care needs such as tracheostomy care. Despite this, the facility assessment indicated that tracheostomy care was a service provided, yet staff were not adequately prepared to deliver this care, resulting in repeated hospital transfers and, in one case, a resident death.
Removal Plan
- Tracheostomy in-service was completed
- All nurses, including agency nurses, were educated