Failure to Ensure Proper Tracheostomy Care and Documentation
Penalty
Summary
The facility failed to ensure proper tracheostomy care for a resident with chronic respiratory failure, ventilator dependence, functional quadriplegia, and a persistent vegetative state. According to facility policy, tracheostomy ties should be changed every seven days, after showers, or when visibly soiled. The resident's Respiratory Administration Record included an order to change the trach ties weekly and as needed, but the August Medication Administration Record did not reflect this order. Observations and interviews revealed that there was no documentation of tracheostomy tie changes for the month of August, and staff confirmed that the order for changing the ties had lapsed when the resident was in and out of the hospital. Interviews with staff, including an LPN, a respiratory therapist, and the Director of Respiratory, indicated that while the responsibility for changing the tracheostomy ties was understood, the actual documentation and consistent performance of this task were lacking. The Director of Respiratory acknowledged the absence of documentation and noted that the issue was only discovered upon review. The DON stated that staff are checked off on this skill during annual training, but this did not ensure ongoing compliance with the required frequency of tracheostomy tie changes or proper documentation.