Failure to Develop Comprehensive Tracheostomy Care Plan
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan for a resident with a tracheostomy. The facility's policy requires that each resident have a care plan addressing their individualized needs, including medical, nursing, mental, and psychosocial aspects, with measurable objectives and timeframes. Despite this, there was no documented evidence of a care plan specifically addressing tracheostomy care, treatments, or goals for the resident who had a non-traumatic brain injury and respiratory failure requiring a tracheostomy tube. The resident's medical record included physician orders for continuous oxygen via tracheal collar, tracheal suctioning, and tracheal care every shift and as needed, but these interventions were not reflected in a comprehensive care plan. Interviews with facility staff, including a nursing supervisor and the Director of Nursing, confirmed that a tracheostomy care plan should have been created at admission and updated as needed. The staff acknowledged that the absence of such a care plan meant there was no formal guidance for the care and treatments associated with the resident's tracheostomy. The deficiency was cited under 10 NYCRR 415.11(c)(1) for failing to ensure a comprehensive care plan was developed and implemented to meet the resident's needs.