Failure to Obtain Physician Order for Tracheostomy Suctioning
Penalty
Summary
The facility failed to obtain a physician’s order for tracheostomy suctioning for one resident who required this care. The facility’s Tracheostomy Care policy dated 03/02/23 stated that staff would provide care and suctioning for residents with a tracheostomy in accordance with standard practice guidelines. A baseline care plan for Resident #1 dated 01/14/26 documented that the resident had a tracheostomy and required suctioning, and an admission assessment dated 01/21/26 showed the resident had severely impaired cognition with a BIMS score of 07, required suctioning and tracheostomy care, and had a diagnosis of chronic obstructive pulmonary disease. However, a review of physician orders from 01/14/26 through 01/27/26 showed no order for tracheostomy suctioning. The DON confirmed that Resident #1 should have had a physician order for tracheostomy suctioning and that no such order was present. An LPN reported that on 01/26/26 the resident’s family stated the resident needed to be suctioned; the resident was not in distress and was suctioned via the tracheostomy after eating and after the family left, and the LPN stated the resident’s tracheostomy was suctioned regularly despite the absence of a physician order. This deficiency centers on the provision of tracheostomy suctioning without a corresponding physician order, despite documented care needs and facility policy requiring care in accordance with standard practice guidelines.
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