Failure to Provide Privacy During Tracheostomy Care
Penalty
Summary
The deficiency involves a failure to maintain personal privacy and dignity for a resident during tracheostomy care. A licensed vocational nurse (LVN J) was observed on 12/31/2025 at 9:37 a.m. providing tracheostomy care to Resident #8 with the resident’s room door open, the curtain between the A and B beds open, and the window blinds open. During a subsequent interview, LVN J acknowledged having received training on resident privacy and stated she should have closed the room door and pulled the privacy curtain while providing tracheostomy care, and that providing privacy during care is important for resident dignity. The DON also stated that staff members are expected to pull privacy curtains and close a resident’s room door when any resident care, including tracheostomy care, is provided, and confirmed that staff had been trained on resident privacy. Resident #8’s records showed she was an older adult female with anoxic brain damage, dementia, and tracheostomy status, admitted with multiple complex medical needs. Her quarterly MDS dated 09/23/2025 documented severely impaired cognitive skills for daily decision making, impaired upper and lower extremities, and total dependence on staff for all ADLs and bed mobility. She had an indwelling catheter, a feeding tube for nutrition, and received tracheostomy care, oxygen therapy, and suctioning. Treatment orders included changing trach ties daily and as needed for soiling. The facility’s Resident Rights policy stated that residents have the right to a dignified existence and to be treated with dignity and respect for their personal integrity, which was not followed during the observed episode of tracheostomy care.
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