Failure to Provide Physician-Ordered Tracheostomy Care and Equipment Changes
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident requiring tracheostomy care and tracheal suctioning, as ordered by the physician and consistent with professional standards of practice. Specifically, staff did not perform the prescribed trach care, including changing the trach aerosol tubing, mask, jet nebulizer bottle, water trap, and trach ties according to the schedule outlined in the physician's orders. Documentation in the Treatment Administration Records (TAR) for multiple dates showed that these tasks were not completed as required, and staff interviews confirmed that some care was either not performed or not documented. The facility's own policy required daily and PRN tracheostomy care using sterile technique, but this was not consistently followed. The resident involved had significant medical needs, including lymphoma, immunodeficiency, dysphagia, and a tracheostomy, and was dependent on staff for respiratory care. Observations and interviews revealed that the resident produced large amounts of thick mucus, required frequent suctioning, and was at increased risk for infection due to his immunocompromised status. Despite these needs, there were repeated failures to change respiratory equipment and trach ties as ordered, and staff could not consistently explain or document when or if these tasks were performed. The resident was eventually admitted to the hospital with brown emesis from the mouth and trach, and was diagnosed with MRSA bacteremia. Hospital staff noted that the trach had not been changed in a long time. Interviews with nursing and respiratory staff indicated a lack of clarity and follow-through regarding the completion and documentation of trach care. Some staff admitted to not documenting care, while others were unaware of discontinued orders or the reasons for missed care. The resident himself communicated that staff did not change the equipment as ordered, attributing it to staff not wanting to do the work. The DON was unaware of several missed or discontinued orders and did not follow up after the resident's hospital admission. These failures were identified through observation, interview, and record review, and resulted in an Immediate Jeopardy finding.
Removal Plan
- Identified resident was transferred to the hospital for further evaluation and treatment.
- The identified resident will be re-admitted if orders for such.
- Education will be completed regarding following physician orders for trach care to include changing trach aerosol tubing, mask, nebulizer bottle, water trap, trach ties and trach color as ordered.
- This education will be provided to current licensed nursing staff by the Director of Nursing/Respiratory Therapist and/or Regional Nurse Consultant.
- This training will be provided prior to staff working.
- Licensed staff will not provide direct care to residents until training is completed.
- Divisional Clinical Nurse reviewed facility's policy and procedures for tracheostomy care. No changes made.
- No new patients/residents requiring tracheostomy care/tracheal suctioning will be admitted until 100% of licensed staff have been trained and deemed competent.
- Two additional residents requiring respiratory/tracheostomy care and tracheal suctioning will be seen by the attending physician, or medical director to ensure no negative assessment findings.
- DON/Designee conducted an audit of current residents and tracheostomy supplies to validate trach supplies were available at bedside.
- The Director of Nursing will begin immediate in-servicing of LVN A, RN B, and LVN C, on the following: Completion and documentation of physician ordered tracheostomy care; Return demonstration of trach care w/competency documented.
- Licensed staff will ensure that the orders for trach care will include changing trach aerosol tubing, mask, nebulizer bottle, water trap, trach ties and trach collar as ordered.
- DON/designee will review MARs/TARs daily to validate trach care orders are carried out.
- LVN A, RN B, and LVN C staff will not be allowed to begin their shift until they have received the education/competency as noted above.
- Licensed weekend staff will be provided with 1:1 re-education on care for patients with tracheotomies. The education will include competency for tracheal care, suctioning, tubing changes, and documentation.
- The Director of Nursing, Assistant Director of Nursing or Regional Nurse Consultant will complete the following until substantial compliance has been met and achieved: Daily audits of residents requiring respiratory/tracheostomy care and tracheal suctioning will be reviewed to ensure that physician orders for such are documented.
- The facility will continue to provide the in-servicing as noted above to newly hired licensed staff, annually and as needed.
- The Director of Nursing or Assistant Director of Nursing will audit licensed nurses training and competency records to ensure tracheostomy care/tracheal suctioning training compliance.
- Nurse Managers will round on trach patients on weekends to validate trach care performed and there are no signs/symptoms of infection. Any issues identified will be addressed immediately.
- All components of this plan of correction will be submitted to the facility QAPI meeting and additional recommendations will be made until substantial compliance has been achieved.
- The Director of Nursing, Assistant Director of Nursing and Regional Nurse Consultant is responsible for the corrections and continued monitoring.
- The Medical Director was notified and agrees with the plan of removal.