Incomplete Documentation of Tracheostomy Care and CPR Events
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with a tracheostomy, specifically regarding the documentation of care and services related to the tracheostomy and the recording of events during a Cardiopulmonary Resuscitation (CPR) Code. The facility's policy required detailed documentation of tracheostomy suctioning, including the date and time, type and size of catheter, amount of negative pressure used, and characteristics of secretions, as well as monitoring of oxygen saturation and pulse. However, the resident's records lacked documentation of the type and size of the suction catheter and the amount of negative pressure used. Additionally, physician's orders for tracheal suctioning and inner cannula changes were not signed off as completed on the Treatment Administration Record (TAR) for the specified date. During a code event, staff documented the CPR narrative on individual pieces of paper, which was later summarized on the Emergency Code Documentation Form. The narrative on the form did not include key details such as the number of shocks administered via the AED and the dislodgement of the tracheostomy tube, despite these events being described by staff during interviews. The Director of Nursing confirmed that these details should have been documented in both the Nursing Progress Note and the Emergency Code Documentation Form, but were not.