Failure to Implement Preventative Measures for Resident Repeatedly Removing Tracheostomy Tube
Penalty
Summary
The deficiency involves the facility’s failure to implement preventative measures for a resident with a known history of attempting self-extubation of a tracheostomy tube. The resident was an 84-year-old female with diagnoses including intracerebral hemorrhage, anxiety disorder, unspecified dementia, tracheostomy status, acute respiratory failure, depression, hypertension, atrial fibrillation, and type 2 diabetes. On admission, she had a tracheostomy with ventilatory support, severe cognitive impairment per MDS (BIMS score of 00), left-sided weakness from a prior stroke, and a history of grabbing and pulling at items within reach, including her gastrostomy tube. Her care plan identified anxiety and risk for respiratory complications related to respiratory failure, but there were no documented interventions addressing her behavior of pulling at the tracheostomy tube. Progress notes show repeated episodes of the resident removing or attempting to remove respiratory equipment. On the evening of admission, documentation indicated she pulled off her trach collar three times, with RT noting they would continue to monitor. The following morning, staff documented that she was extremely restless, had to be repositioned multiple times, and tried multiple times to remove the vent mask, causing two skin tears on her upper right chest. Later that same morning, it was documented that she had pulled herself off the trach collar four times and emptied the humidity water bottle twice, with staff moving the O2 tank and water bottle to the foot of the bed and continuing to monitor while her O2 saturation remained in the mid-90s. Subsequent documentation shows that the resident ultimately decannulated herself, with RT unsuccessfully attempting three times to replace the trach before the stoma closed, after which she was placed on nasal cannula oxygen. Notes also indicate she continued to remove her nasal cannula, though her oxygen saturations generally remained within normal limits. Interviews with the DON, MDS/Care Plan Coordinator, and an LPN confirmed that the resident had a history of pulling at her tracheostomy tube, feeding tube, and other items, and that she was very anxious. The LPN reported that an abdominal binder was used over the G-tube site and items were kept out of her reach, but stated there was nothing they could do to keep her from pulling at the tracheostomy tube and that it was inevitable she would pull it out. Despite the facility’s Problematic Behavior Management Clinical Protocol requiring identification and implementation of non-pharmacologic interventions for problematic behaviors and assessment of whether a resident is a danger to themselves, there was no documentation of specific preventative interventions for the resident’s repeated attempts to remove her tracheostomy tube.
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