Failure to Provide Safe and Appropriate Tracheostomy Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care, including tracheostomy care and suctioning, for residents who required such interventions. One resident, who was admitted with a tracheostomy and a history of acute respiratory failure, did not have physician orders in place for trach care or suctioning since admission. Nursing staff did not perform regular tracheostomy care, citing discomfort and lack of training, and instead allowed the resident to perform his own trach care without supervision or documented competency. The resident was observed reusing disposable cannulas and cleaning them in non-sterile conditions, and his responsible party reported having to bring supplies from home. The resident was later hospitalized and diagnosed with pneumonia after experiencing respiratory distress and low oxygen saturation. Another resident with a tracheostomy and severe cognitive impairment also did not receive trach care and suctioning according to professional standards. Observations revealed that a nurse performed trach care without following infection control protocols, such as proper hand hygiene, use of sterile equipment, and appropriate suctioning technique. The nurse also reported not receiving adequate training or periodic competency evaluations for trach care, and had difficulty locating necessary supplies. Multiple staff interviews confirmed gaps in training, lack of skill checks, and uncertainty about who was responsible for trach care education and oversight. Record reviews showed that the facility's policies required physician orders for trach care, adherence to sterile technique, and regular staff training and competency checks. However, these requirements were not met, as evidenced by the absence of orders, improper care practices, and lack of documentation of staff competencies. The failures were identified as placing residents at risk for infection, respiratory distress, and other complications, and resulted in the identification of an Immediate Jeopardy situation by surveyors.