Failure to Provide and Document Tracheostomy Care per Physician Orders
Penalty
Summary
The facility failed to assess and provide tracheostomy care according to physician's orders for one resident who was in a vegetative state, non-verbal, and had a tracheostomy. Documentation review revealed multiple instances where required assessments of the stoma site and tracheostomy care were missing on both day and night shifts across several dates. The Director of Nursing stated that responsibility for tracheostomy care had been transferred from respiratory therapy staff to nursing staff, which may have contributed to the missed treatments due to possible confusion over which staff were responsible. Facility policy required that respiratory therapy or trained and competent personnel provide and document tracheostomy care twice within 24 hours, but this was not consistently done as required.