Failure to Maintain Required Back-Up Tracheostomy Supplies at Bedside
Penalty
Summary
Facility staff failed to ensure that required back-up tracheostomy supplies were available at the bedside for a tracheostomy-dependent resident. The facility’s “Tracheostomy Care” policy required that a suction machine, suction catheters, correctly sized cannulas, and an ambu bag be easily accessible for immediate emergency care. The resident’s care plan documented that the resident had a size 6 Shiley tracheostomy with a trach collar and directed staff to keep an extra trach tube and obturator at the bedside. The resident’s medical record showed multiple diagnoses including respiratory failure with hypoxia, tracheostomy dependence, aphasia, and seizure disorder, and a quarterly MDS documented that the resident was severely cognitively impaired, dependent for all ADLs, and dependent on respiratory treatments including oxygen therapy, suctioning, trach care, and invasive mechanical ventilation. A physician’s order also specified that a back-up size 6 uncuffed trach be kept at the bedside every shift. During an observation, surveyors noted that there was no back-up size 6 uncuffed tracheostomy tube or obturator at the resident’s bedside. When the assigned LPN was asked where the back-up trach was kept, she searched the bedside area but could not locate it and stated that although she had worked with the resident a few times, it had never come to mind to check for the extra supplies. The unit manager also searched the bedside area without success and then returned with a plastic bag containing only gauze sponges, surgical tape, and bandage scissors, and did not provide information about the back-up trach or its size. The DON acknowledged that extra trach supplies, including the trach and correct size lumen, must always be at the bedside for emergencies, confirming that the required back-up tracheostomy equipment was not in place as ordered and as required by facility policy and the resident’s care plan.
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