Failure to Provide and Document Tracheostomy Care for Two Residents
Penalty
Summary
Facility staff failed to provide required tracheostomy care for two residents, as evidenced by missing documentation on the respiratory administration records. For one resident, a physician's order specified tracheostomy care every shift and as needed, but the clinical record showed that care was not documented on several night shifts in January and February. The facility's policy required tracheostomy care at least once daily for established tracheostomies and at least every eight hours for unhealed tracheostomies. Interviews with nursing staff confirmed that tracheostomy care includes cleaning around the stoma, changing gauze, and changing the inner cannula, and that completion of care is evidenced by signing the respiratory administration record. A second resident also had a physician's order for tracheostomy care every shift and as needed, but the clinical record revealed multiple instances in March and April where care was not documented during both day and night shifts. The absence of signatures on the respiratory administration record indicated that tracheostomy care was not provided as ordered. Facility administrative staff were made aware of these concerns during the survey process. No additional information was provided prior to the survey exit.