Failure to Provide Timely Tracheostomy Suctioning Results in Resident Neglect
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN), identified as Staff A, repeatedly refused or delayed providing suctioning care for a resident who was dependent on staff for tracheostomy management. The resident had physician orders for deep suctioning as needed, with specific instructions for frequency and technique. Despite these orders, documentation revealed that Staff A did not record performing suctioning during his shifts, and multiple staff and the resident reported that Staff A would not respond promptly to requests for suctioning, often requiring the resident to activate the call light multiple times and for certified nursing assistants (CNAs) to repeatedly notify Staff A before the care was provided. The resident, who had diagnoses including acute and chronic respiratory failure with hypoxia, functional quadriplegia, and a tracheostomy, reported experiencing severe anxiety and fear for his life when suctioning was not performed as needed. The resident stated that this neglect occurred nearly every night Staff A worked, and that all overnight CNAs were aware of Staff A's refusal to provide timely suctioning. Staff interviews corroborated the resident's account, with CNAs stating that Staff A would often refuse to suction the resident, sometimes claiming he had already done so or was busy, and that the resident appeared scared and anxious as a result. The director of nursing (DON) was made aware of concerns regarding the frequency and timeliness of suctioning, including receiving calls and text messages from staff about the issue. However, the DON did not identify or document any concerns with Staff A's performance at the time, and there was no evidence that the DON was aware of the ongoing pattern of neglect until later. Staff A denied refusing care and claimed to have provided suctioning as needed, but this was contradicted by multiple staff and the resident's statements, as well as the lack of documentation in the medical record.