Failure to Ensure Competent Tracheostomy Care by Nursing Staff
Penalty
Summary
The facility failed to ensure that nursing staff possessed the appropriate competencies and skills to provide safe and effective care for a resident with a tracheostomy. Direct observation revealed that a nurse performed tracheostomy care and suctioning without adhering to professional standards of practice, including failure to perform hand hygiene, improper use of gloves, use of non-sterile equipment, and not following required procedures for oxygenation and suctioning. The nurse did not clean the resident’s trach stoma or change saturated dressings, and did not check or adjust oxygen prior to or during the procedure. The resident was observed with excessive secretions, soiled dressings, and was visibly distressed during the care. Interviews with multiple nursing staff indicated a lack of adequate training and competency validation in tracheostomy care. Several nurses reported not receiving hands-on training, periodic evaluations, or instruction on the use of trach care equipment. One nurse stated she had only practiced on mannequins and would require supervision to perform the procedure on a resident. Another nurse reported not being familiar with the resident or the necessary equipment, and both nurses expressed the need for reeducation on trach care. The responsible director of nursing was unable to provide documentation of staff competency evaluations when requested. The facility’s own policies required sterile technique, hand hygiene, and specific steps for tracheostomy care and suctioning, which were not followed during the observed incident. The lack of staff training, competency checks, and adherence to policy resulted in an Immediate Jeopardy situation, as staff were not equipped to safely care for residents with tracheostomies. The deficiency was identified through direct observation, staff interviews, and review of facility records and policies.
Removal Plan
- The facility will remove all tracheostomy clinical capabilities. All residents with tracheostomies will be safely discharged in coordination with their responsible parties, and no residents requiring tracheostomy care remain in the facility.
- Residents #2 and #3 were identified as potentially affected and will be discharged accordingly. They have been assessed by Consultant RN and found to be safe, unaffected by deficiencies and in no distress. They will be discharged upon formulation of discharge plan. Resident #2 will be discharged to SNF and Resident #3 will be discharged to hospital pending SNF placement due to need for dialysis.
- A Special Bulletin inservice with sign-in sheet. RN consultant to review. The Facility does not maintain a policy for residents to provide their own treatments outside of self-administration of medication; if a resident refuses or is non-compliant with ordered nursing procedures or treatments it will be documented in progress notes, physician notified, and care plan will be updated. All clinical staff and admissions team members have been notified by mass message that we will no longer accept residents or referrals for tracheostomy dependent residents.
- The facility will remove all tracheostomy clinical capabilities. All residents with tracheostomies have been safely discharged in coordination with their responsible parties, and no residents requiring tracheostomy care remain in the facility.
- IJ and POR reviewed during adhoc QAPI with medical director, administrator, outside consultant and DON; POR and POC will be reviewed during monthly QAPI and revised as needed, to sustain improvement. An adhoc QAPI was conducted via teleconference to update education plan and review of revisions. An adhoc QAPI was conducted including RT to discuss further areas of revision to POR and engagement of RT, duties and oversight responsibilities. A QAPI will be held to notify and discuss plan and new clinical capabilities with medical director.