Failure to Ensure Ordered Tracheostomy Changes Were Completed and Accurately Documented
Penalty
Summary
The facility failed to ensure a resident with an anoxic brain injury received complete tracheostomy (trach) changes as ordered by the physician and respiratory therapist (RT). The resident was admitted with a trach and had physician orders for a complete trach change every three months in April, July, October, and January, specifying a size six extra-long Shiley cuffed trach tube with disposable inner cannula. Review of the electronic medical record (EMR) showed missing or blank Treatment Administration Records (TARs) for some of the months when trach changes were due, including January and October, and there were no corresponding RT progress notes documenting that the ordered trach changes were completed. Documentation showed that on some dates nursing staff (RNs) recorded that they had changed the trach, but during interviews those RNs stated these entries were errors and that only the physician or RT should perform a complete trach change. RT progress notes and interviews further demonstrated inconsistency and lack of awareness of the specific physician orders. The RT documented performing trach care only on several dates and stated in interview that she tried to come weekly but had not been able to recently due to medical issues, and that the last time she changed the resident’s trach was in December. She also stated she was not aware of the physician’s specific schedule for trach changes and clarified that a trach change meant removal of the trach and was to be done only by the RT. The DON stated that the TAR was expected to reflect the care provided and that nursing needed to ensure documentation was correct, while the Medical Director stated that clinical staff were to follow his orders and notify him if they could not be implemented, and that the complete trach changes were required to maintain patency, prevent infections, and provide cleanliness.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.