Ftag of the Week – F695 Respiratory/ Tracheostomy Care and Suctioning (Pt 3)

In Part 3 of our CMSCG “Ftag of the Week” for F695, we will review additional care and services that fall under this category, namely, C-pap and Bi-pap for obstructive sleep apnea (OSA) as well as tracheostomy care and suctioning.


There are many types of treatments that can address OSA, which results in the upper airway collapsing during sleep. Per the Interpretive Guidance in Appendix PP, tongue-retaining devices or weight reduction treatments can be considered in addition to CPAP and BiPAP. Continuous positive airway pressure (CPAP) uses an external device which administers air through the nose at a fixed pressure to keep the upper airway unblocked. Bi-level positive airway pressure (BiPAP), as its name implies, can generate two pressure levels instead of just one, as with a CPAP. 

If a resident is using one of these devices, there need to be physician orders in place, even if the device was brought from home or the community. Documentation must include the indication for use, equipment settings, and when to use the device. The resident’s record should be routinely updated to document staff ongoing assessment of the resident’s respiratory status and resident’s response to therapy. Oftentimes, residents may refuse to wear these devices at night, so it is important to ensure documentation is sound, including resident education on the need for use of the device.

Sounds simple enough, right? Well, there are many potential pitfalls, according to CMSCG Clinical Consultant, Mary Quinn, RN. Let’s see where you need to pay attention.

  • Make sure there is process in place to identify and communicate equipment needs prior to admission to the facility. A delay in ordering/receiving a needed machine can be problematic, i.e., a MAR which reflects application not administered for several days “pending delivery.”
  • The orders for use must be inclusive of all the required settings. This includes who sets it up, who is responsible for making adjustments.  All staff responsible for assisting residents with use of either of these breathing assist devices should have a competency in place.
  • Do you have policies in place for cleaning/storage?  Documentation should include the frequency and products used. Monitor the resident rooms to determine where and how the equipment is stored.
  • If the resident is participating in the management of the equipment, make sure there is supporting documentation indicating they have been observed to utilize the correct infection control techniques for cleaning and storage.
  • If a resident uses home equipment, is that addressed in your policy? Did someone from Engineering check the equipment and properly tag it? 
  • Regarding refusals – if the resident is refusing the use of the device, there needs to be evidence of physician notification and the non-compliance should be addressed with ongoing education.

Throughout this blog series, you’ve probably noticed references to competencies. Here’s another one. Make sure you have current competencies in place for staff who are responsible for the care of residents using these devices. Do your records have documentation reflecting the machine is non-functioning but when checked by a knowledgeable person, no issue is identified? It happens.

Tracheostomy Care/Suctioning

One of the more complicated types of care and services included in F695 is tracheostomy care and suctioning. This is because someone requiring these services, generally, is dependent on staff for this care, unlike a resident who may be able to apply his/her CPAP. With that in mind, it is essential that staff provide care in accordance with physician orders, the resident assessment and the CCP since there are many areas that need to be addressed for this care. According to the guidance under F695, the following must be considered and addressed when developing the plan of care for a resident with a tracheostomy:

  • Positioning
  • Range of motion
  • Nutrition and hydration
  • ADLs
  • Bowel and bladder management
  • Communication – Don’t forget, if the resident is non-verbal, there needs to be a process in place to assist with communication.
  • Psychosocial needs
  • Monitoring for resident-specific risks and complications
  • Suctioning – The need for suctioning is typically based on the resident’s individual needs and should always include a prn indication.  Don’t forget – appropriate use of PPE and good infection control practices would be a focus of all observations by a surveyor.

Don’t forget – appropriate use of PPE and good infection control practices would be a focus of all observations by a surveyor.

Even if you’ve got all that in place, there’s still the potential for issues to arise. Here are some helpful tips and reminders:

  • Does your policy indicate routine trach changes – how often/by who?
  • Trach care policies should include the procedures involved for disposable as well as non-disposable inner cannulas as well as the changing of trach ties/holders.
  • Does your policy indicate the process for replacement of a dislodged trach? Is the resident being transferred to the ER, or is your staff responding? If so, when was the last time they had a competency completed?
  • Do you complete an incident/occurrence report if a trach is accidently dislodged? This isn’t a bad idea since it may help identify the cause and include a recommendation for follow-up, such as additional staff education.
  • Emergency equipment should be readily accessible i.e., ambu bag at/near the bedside.
  • The order should include the specific type/size of device in use. Is a replacement readily accessible, if needed? It should be.
  • Speaking valves, if used, should have an order for use and are recommended to be removed for sleep.  There is usually a directive on the length of time the valve should be in place.
  • Make sure all residents with tracheostomies have comprehensive skin assessments completed on a routine basis. Equipment-related skin breakdown results in a potentially negative outcome for the resident.  We don’t just mean a pressure injury on the back, heels, buttocks from a resident lying on back for extended periods.  For example, what about skin breakdown under the trach collar?

In the final part of this “Ftag of the Week” blog series for F695, we will review mechanical ventilator use and discuss some additional information about staff competencies and documentation best practices.

To learn more about CMS Compliance Group, Inc., a regulatory compliance and quality improvement consulting firm working with skilled nursing and other post-acute providers, visit our website. For information on our consulting services for nursing homes, please call 631.692.4422 or email info@cmscg.net.

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