Failure to Provide Safe and Appropriate Tracheostomy Care
Penalty
Summary
Nursing staff failed to provide safe and appropriate respiratory care for residents with tracheostomies, as evidenced by a lack of knowledge, skills, and necessary supplies. Multiple staff members, including RNs, LPNs, and CNAs, reported not having received training on tracheostomy care or CPR for residents with tracheostomies. During emergencies, staff were unable to properly ventilate residents with tracheostomies, as they did not know how to use the bag-valve-mask (BVM) with a tracheostomy tube and instead attempted to ventilate via the mouth, which is not appropriate for these residents. In several cases, staff were unable to suction or replace tracheostomy tubes due to lack of training or proper equipment, resulting in inadequate airway management. Two residents with tracheostomies, both full code, experienced respiratory distress and required CPR. In both cases, staff did not provide ventilation through the tracheostomy tube during resuscitation efforts, and only performed chest compressions or attempted to bag over the mouth. There were multiple reports of staff not having the correct tubing or not knowing how to attach the BVM to the tracheostomy. Both residents died in the facility, with death certificates pending. Other residents with tracheostomies were sent to the hospital for issues such as secretions, mucus plugs, or tracheostomy tube dislodgement, which could not be managed by facility staff due to lack of training or supplies. Emergency medical services and local fire department personnel reported frequent calls to the facility for non-emergent tracheostomy care needs, such as suctioning or cleaning, which should have been managed by facility staff. In several instances, EMS had to use their own equipment to suction residents, as the facility lacked necessary supplies like suction tips. Staff interviews confirmed that there was no routine or formal training on tracheostomy care, and some staff expressed discomfort or lack of proficiency in caring for residents with tracheostomies. The facility's own policy required routine tracheostomy care and suctioning as needed, but this was not consistently provided.
Removal Plan
- Tracheostomy in-service was completed and all nurses, including agency nurses, were educated prior to the start of their next scheduled shift.