Failure to Develop Comprehensive Care Plan for Resident Repeatedly Removing Tracheostomy Tube
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan addressing a resident’s repeated behavior of pulling out her tracheostomy tube. The resident was admitted with multiple complex diagnoses, including chronic respiratory failure with an indwelling tracheostomy, chronic encephalopathy with delirium, laryngeal hypoplasia, epilepsy, anxiety disorder, obesity, functional quadriplegia, dysphagia, and type 2 diabetes mellitus. Her History and Physical documented that she remains in a chronic encephalopathic state with delirium and repeatedly pulls out tubes and her tracheostomy at the nursing home. The existing care plan noted that she has a tracheostomy and is at risk for shortness of breath, with approaches such as ensuring trach ties are secured and outlining tube-out procedures, and it also documented that she uses anti-anxiety medications and that she pulls out her trach often, with approaches limited to administering anti-anxiety medications and monitoring for side effects and effectiveness. Despite documentation in the H&P and progress notes that the resident has pulled out her trach tube at least 28 times since admission, resulting in at least 18 calls to 911 and transfers to the ER when staff could not reinsert the tube, the facility did not create or implement a specific care plan with targeted interventions for this behavior. The DON reported that the resident pulls out her trach daily, sometimes multiple times a day, and stated that Ativan had been increased and that the hospital uses wrist restraints, which the facility does not use. The DON also stated she thought the facility had requested a psychiatric consultation that was refused by the resident’s son, but she was unable to provide evidence that such a consult was ordered or refused. The DON further reported that the resident’s room placement near the nurses’ station allowed for more frequent checks, but the surveyor found no evidence of implemented interventions beyond increasing Ativan, and noted that tracheostomy care and treatment were not included in the Facility Assessment.
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