Failure to Ensure Safe and Documented Tracheostomy Care and Skin Assessment
Penalty
Summary
The facility failed to implement effective systems for entering and documenting tracheostomy care orders, resulting in the absence of tracheostomy care orders on the Treatment Administration Record (TAR) for several months. This led to inconsistent and undocumented tracheostomy care for a resident with a history of anoxic brain damage, tracheostomy status, and severe cognitive impairment. Multiple nurses reported that they did not document tracheostomy care because there was no order on the TAR, and some were unsure of the required frequency or specific procedures for tracheostomy care, such as changing the inner cannula or inspecting the skin under the collar. During direct observation, a nurse was seen picking up oxygen tubing from the floor and reattaching it to the resident's respiratory equipment, which was immediately corrected by another nurse due to infection control concerns. The nurse admitted that she typically reconnected tubing without replacing it when it became disconnected, not recognizing the need for sterility at the connection site. Additionally, the facility did not have effective systems in place to identify and assess avoidable moisture-associated skin damage (MASD) in the resident's neck folds. The MASD was only discovered incidentally during tracheostomy care, and prior skin assessments had not included the neck area unless staff were alerted to a problem. Interviews with nursing staff revealed a lack of clarity regarding responsibilities for tracheostomy care, with some nurses stating they had never performed the care or were unsure which shift was responsible for specific tasks. The wound nurse confirmed that skin folds, especially in heavier residents, should be assessed regularly, and that the MASD was found in a moist, sweaty area under the tracheostomy ties. The respiratory therapist and medical director both described appropriate tracheostomy care procedures and assessment expectations, but these were not consistently followed or documented by nursing staff due to the missing orders and lack of clear protocols.