Failure to Provide Tracheostomy Care Due to Lack of Orders and Documentation
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required tracheostomy care. Upon admission, the resident had a documented tracheostomy, as indicated in the hospital discharge instructions, which specified the need for portable trach suctioning and identified the presence of a Shiley trach. However, the facility's admission records, care plans, and assessments did not reflect the presence of a tracheostomy, and no orders for tracheostomy care or suctioning were entered into the system. As a result, there was no evidence that tracheostomy care was provided during the resident's stay. Interviews with nursing staff and facility leadership revealed inconsistent practices and a lack of recall regarding the resident's tracheostomy status. Staff members described standard procedures for admitting residents with tracheostomies, including the expectation to enter standing or provider-verified orders for tracheostomy care and suctioning. Despite these protocols, none of the staff interviewed could confirm that such orders were entered or that care was provided for this resident. The facility's documentation and in-service records also did not show any recent training or education on tracheostomy care for staff. The resident's medical history included hypertensive heart disease, chronic kidney disease, and thyroid cancer, and he was alert and oriented at the time of admission. The lack of tracheostomy care orders and documentation of care, despite clear hospital discharge instructions, resulted in the resident not receiving necessary respiratory care during his stay. This deficiency was identified through record review and staff interviews, which confirmed the absence of required orders and care.