Park View Care Center

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

asked what a prudent nurse would do in this case, LVN A stated she should have stopped and began the tracheostomy care process from the beginning with fresh supplies. LVN A was asked what her expectations were of maintaining sterile field during a procedure that required it, especially with a resident on enhanced barrier precautions, LVN A replied to prevent further spread of bacteria from the resident to herself and other surfaces. During an interview on 11/07/2025 at 12:25 PM, the DON revealed she was employed at

this facility for 2.5 months. The DON revealed tracheostomy care training was provided once per week and provided 1 to 1 training with the ADON the facility had a Respiratory Therapist that comes to the facility. The DON revealed the ADON then trained the nurses in tracheostomy care. The DON revealed on the days the RT was in house, the RT provided tracheostomy care. The DON stated she (meaning herself) observed the nurses provide tracheostomy care occasionally. The DON stated tracheostomy skill competency was checked annually by the RT. The DON stated all facility P & P were currently written by corporate staff and

she had not reviewed the P & P for tracheostomy care or suctioning care. The DON revealed that a sterile field was necessary to prevent infection and the expectation of nurses that broke sterile field was to stop immediately and start over with all new supplies. On 11/10/2025 at 2:00 PM, a telephone interview was conducted with a Respiratory Consultant A. This contact stated she was a consultant for this facility, not employed as a respiratory therapist. The RC stated she was contracted with this facility for three months.

The RC revealed she provided all tracheostomy care and suctioning training to staff nurses based on her 17-year hospital experience. This RC said she was not familiar with the current facility tracheostomy and suctioning P & P. Record review on 11/07/2025 of Tracheostomy Suctioning and Tracheostomy Care P &P: -Tracheostomy Care Policy: Dated 06/01/2025Policy: To aseptically clean a tracheostomy site and trach tube free from mucous buildup, maintaining tube patency, reducing risk of infection and maintaining skin integrity at the stoma site. Tracheostomy care should be provided every 8 to 12 hours or as indicated by order of physician. -Tracheostomy Care Procedure: 1. Verify physician's order, including procedure to be done, frequency, physician's signature.2. Gather necessary supplies: PPE Pulse ox Suction set-up (should already be bedside) Ambu bag (should already be bedside) Emergency trach replacement tube same size and one smaller (should ALWAYS be present bedside)Disposable inner cannula (if applicable)Sterile normal saline or sterile waterTrach care kit: 4x4 sterile gauze, cotton tipped applicator, drape, trach dressing (split drain sponge), brush, 2 or 3 basins3. Identify patient.4. Knock on door, introduce self to patient, explain procedure and provide for privacy.5. Wash hands.6. Position patient in semi-Fowler's position (if able) and elevate bed to appropriate height.7. Perform pre-assessment: breath sounds, respiratory rate, heart rate, pulse-ox (if applicable).8. Suction trach if necessary and discard gloves and used supplies.9. Wash hands and re-glove.10. Open trach care kit and establish field. -Suctioning Policy dated 06/01/2025Policy: To maintain oxygenation and patent (open) airway by removing thick mucus and secretions from the trach tube and lower airway Suctioning Procedure: .7. Place catheter tip in distilled water or sterile saline, occlude catheter port with thumb and suction a small amount of water or saline through the catheter.

Event ID:

Facility ID:

If continuation sheet