Ftag of the Week – F695 Respiratory/ Tracheostomy Care and Suctioning (Pt 4)

Sometimes our CMSCG “Ftag of the Week” for certain regulations is more like an “Ftag of the Month,” and F695 is one of those regs with a lot to cover. In this post, we will wrap up our CMSCG Blog series for F695 Respiratory/ Trach Care and Suctioning by looking at ventilators and some other things to be aware of.

Respiratory Services for Mechanical Ventilation

The revised guidance to surveyors in Appendix PP of the State Operations Manual (SOM) states that the guidance for residents receiving mechanical ventilation only applies to facilities that are providing this type of care, so if this isn’t relevant to your organization, you can choose to skip over this section.

A resident who is ventilator-dependent (ventilator-assisted individual or VAI) requires mechanical assistance to breathe. Mechanical ventilation is a form of life support that either supports normal ventilatory lung function – or replaces it. Some individuals who require this support cannot be weaned from using a vent or have a disease which progressively increases needed ventilator support. These VAIs require long-term, invasive ventilatory support, and often end up residing in a nursing home providing these specialized respiratory services.

The clinical complexity of the care of a resident who requires mechanical ventilation requires an ongoing interdisciplinary approach and their needs typically go far beyond their respiratory status. The IDT for a resident receiving this care should include the resident/ rep, medical, pulmonology, therapy (SLP, PT and/or OT), nursing and dietary. The team is responsible for ensuring a comprehensive assessment and plan for the resident’s respiratory needs is developed. Assessments related to the individual’s cognition, level of consciousness, visual/hearing needs and methods for communication must also be conducted and the results of these assessment have to be taken into consideration when developing an individualized plan of care – no cookie cutter concept. Much like the requirements for trach care outlined last week, the resident’s plan of care also needs to include bowel and bladder management, provision of oral and eye care, monitoring for psychosocial needs, adjunctive interventions and physician ordered monitoring.

It is worth noting that identification of resident-specific risks for potential complications related to vent care need to be identified and care planned for. Per the Interpretive Guidance (IG), some potential complications to be aware of include:

  • Unplanned extubation
  • Development of oral or ocular ulcers
  • Nutrition complications related to tube feedings or gastric distress
  • DVT due to immobility
  • The type/settings of the ventilator, type of airway used and how the staff respond to an activated alarm would likely be monitored closely during survey observation – Make sure your alarms are always ON.

Since a resident who is vent dependent requires staff to assist with the provision of care, providers need to ensure that the plan of care developed can be consistently implemented – and that staff are competent to provide these services. This includes ensuring staff are competent in using life support interventions in the event of an emergency, such as a power outage, or if the resident experiences a cardiac or respiratory complication related to the vent.

Before we wrap up this overview of vent care, here’s a tip from CMSCG President, Linda Elizaitis, RN:

If you are not initiating an incident report for an unplanned extubation, consider implementing such a system.  Self-extubation or “oops” it came out during care or when you turned the resident are events that are worth investigating. How are you assessing a resident for risk to self-extubate and what’s your plan of care?  What is your investigation process when staff reports that the resident self-extubated and, on investigation the event, the resident is totally dependent on staff?

Linda Elizaitis, President, CMS Compliance Group, Inc.

Some Reminders on Competencies

CMSCG Clinical Consultant Mary Quinn, RN, provided the following reminders related to competencies for respiratory care and services:

  • Keep in mind your facility’s staffing practices and ensure it matches the ideal of competent staffing. For example, if a staff member floats to the only unit that has a resident requiring a trach, does he/she get assigned to that resident to give the other staff members “a break?” When did the float last care for a resident with a trach? Is his/her competency current?
  • If you utilize agency nurses, do they have current competencies?

What should be included in a respiratory care competency? Consider at a minimum, based on the level of care provided at your facility:

  • Respiratory assessment/chest inspection – lung sounds
  • Oxygen saturation – vital signs
  • Oxygen administration- nasal cannula, aerosol mask, venti mask (requires high flow oxygen)
  • Percussion/postural drainage
  • Incentive spirometry – education/monitoring
  • Medical nebulizers – inclusive of administration via a trach
  • Trach care — inner canula change, trach holder change
  • PPE requirements — Infection control standards of care
  • Management of speaking valves
  • Suctioning – oral/tracheal
  • Maintenance of equipment
  • Refilling of tanks — as indicated
  • Emergency care – alarm response, emergency equipment, trach dislodgement, use of ambu mask/trach, power outage 

We can’t close this out without one last thought on quality of life.  Do you only give vent-dependent residents a bed bath?  Your respiratory therapist can assist with transport and during a shower / tub bath – now that is quality of life!

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