Failure to Provide RN Coverage and Competent Tracheostomy Care
Penalty
Summary
Facility staff failed to provide competent professional nursing oversight, assessment, and administration of tracheostomy care for three residents on a specialized tracheostomy unit. The facility did not ensure that a Registered Nurse (RN) was present on every shift as required, resulting in lapses in care and medication administration. For one resident, there were multiple missed doses of IV and oral vancomycin following a hospital discharge for sepsis and pneumonia, with documentation showing that antibiotics were not administered as ordered for several days. The resident exhibited worsening symptoms, including fever and low blood pressure, without adequate assessment or intervention, and was ultimately sent to the hospital in critical condition and expired the same day. Staff interviews revealed that LPNs and CNAs often felt unprepared to care for tracheostomy residents and were unsure how to recognize signs of distress or perform safe suctioning. Another resident, who was at high risk for hemorrhage due to anticoagulation therapy, experienced a critical event when an LPN, without RN supervision, performed suctioning after the resident began coughing up blood and lung tissue. The resident's oxygen saturation dropped to a dangerously low level, and the resident was sent to the hospital with a tracheal tear and subsequently expired. The care plan for this resident lacked essential interventions for tracheostomy care, such as oxygen humidification, cannula management, and suction device settings. Staff interviews confirmed that RNs were not always present on the unit, and staff felt inadequately trained to manage tracheostomy care. A third resident, who was non-verbal and dependent on staff for all care, was found deceased on the unit during a shift when no RN was present. The scheduled RN, who was new and inexperienced with tracheostomies, left the facility after realizing she would be the only RN on the unit, and the DON refused to come in to provide coverage. Facility records confirmed that only LPNs were present on the unit at the time, and an RN from another floor had to be called to pronounce the resident's death. The facility's own assessment indicated awareness of the requirement for RN coverage on the tracheostomy unit, but this was not consistently implemented.
Removal Plan
- A Registered Nurse with documented tracheostomy competency training will be assigned to the tracheostomy unit every shift 7 days per week.
- Director of Nursing (DON) or designee will verify and document on assignment sheet the presence of an RN with documented tracheostomy training.
- The Regional Director of Specialty Care or designee will ensure all RN staff scheduled to work on the tracheostomy unit have completed reeducation and competency validation in care of tracheostomy patients, prior to assuming an assignment.
- A roster of RN's will be maintained by the DON or designee and provided to staffing scheduler to ensure immediate coverage in the event of call-off.