Failure to Ensure Nursing Staff Competency in Tracheostomy Care
Penalty
Summary
Nursing staff at the facility were found to lack appropriate competencies in providing tracheostomy care, as evidenced by direct observation, record review, and staff interviews. One nurse was observed picking up oxygen tubing from the floor and reattaching it to equipment connected to a resident's tracheostomy humidifier, a practice that was immediately corrected by another nurse who instructed her to replace all tubing. The nurse admitted to routinely reconnecting tubing that had fallen on the floor without replacing it, and also stated she had not attended the facility's tracheostomy care training. Another nurse, who was an agency staff member, reported having prior tracheostomy care experience but had not received any facility-specific education or training on the procedure, despite having performed tracheostomy care for a resident during her shift. A third nurse, who had recently returned to the facility, stated that her performance in tracheostomy care had not been evaluated since her return and that she had not received any training or education on the subject in the past two months. The facility was unable to provide documentation of tracheostomy care competencies or training for any of the nursing staff reviewed. The only documented training was a skills fair conducted by a respiratory therapist, but attendance records showed that not all relevant staff participated, and there was no evidence that the nurses involved in the deficiency attended the session. Interviews with facility leadership revealed a lack of consistent protocols and documentation regarding tracheostomy care education and competency evaluation. The Staff Development Coordinator position had experienced high turnover, resulting in gaps in training oversight. Although orientation was supposed to include tracheostomy care skills evaluation, no documentation could be found to confirm that this had occurred for the nurses in question. The deficiency was identified for three of eight nursing staff reviewed for tracheostomy care competencies.