Failure to Provide Required Tracheostomy Supplies and Care
Penalty
Summary
A deficiency was identified when a resident with a tracheostomy did not have necessary trach supplies readily available, and required care and treatment were not completed as ordered. The resident, who had diagnoses including tracheostomy, dysphagia, and moderate cognitive impairment, was observed with soiled and dingy trach ties and reported that he had run out of trach ties about a month prior. Facility staff, including the RN Assistant Director of Nursing and LPN, were unable to locate trach ties, inner cannulas, or a spare trach in the resident's room, medication cart, or treatment cart. The search for supplies revealed that while some trach supplies were eventually found in the central supply room, trach ties were not available at all. Interviews with staff revealed inconsistent practices regarding trach care. Several LPNs stated that the resident performed his own trach care, and they did not monitor or assist him, but still documented the care as completed per physician orders. The resident confirmed that his inner cannula had not been changed for weeks and that he had informed nursing staff of this. The RN ADON and Infection Preventionist confirmed that trach supplies, including ties and cleaning materials, should be kept at the bedside and that nurses are responsible for performing and documenting trach care as ordered. Further interviews with the respiratory therapist and other staff indicated that the resident did not keep supplies in his room due to using them up quickly, and that the RT only visited twice a week and did not provide direct care. The facility's policy required verification of physician orders, gathering of supplies, assessment and cleaning of the stoma, changing of the inner cannula, and replacement of trach ties if soiled, with proper documentation. The failure to ensure supplies were available and care was completed as ordered resulted in non-compliance with required standards for respiratory care.