Tracheostomy Care in Skilled Nursing: Step-by-Step Procedure and Staff Competency Checklist

If you work in a skilled nursing facility long enough, you will care for a resident with a tracheostomy. Maybe it's a vent-weaned admission from a long-term acute care hospital. Maybe it's a long-stay resident whose airway was placed years ago and whose family has chosen the facility as home. Either way, the care is high-stakes in a way that most other tasks on the unit are not. The airway is the airway. If something goes wrong with it, the resident does not have minutes to spare while you go look something up.

This article walks through what a complete tracheostomy care procedure should cover in a SNF, why a written staff competency checklist is non-negotiable, and one anatomical distinction that consistently catches new staff off-guard. It is written for Directors of Nursing, staff development coordinators, and clinical educators who are building or refreshing their facility's trach program — not as a substitute for facility protocol or manufacturer guidance, both of which take precedence over anything in a public article.

Why Tracheostomy Care Is a Survey-Exposure Topic

Tracheostomy and respiratory care fall under F695 (Respiratory and Tracheostomy Care) at 42 CFR §483.25(i), which requires that a facility ensure a resident who needs respiratory care receives such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences, and the resident's assessed needs. That language is broad on purpose. A surveyor citing F695 is rarely citing a single missed task — they are usually citing a pattern: the procedure was vague, the staff couldn't describe it consistently, the documentation was thin, and when the surveyor asked the nurse on the floor to walk through what they would do if the tube dislodged, the answer wavered. F695 also overlaps with staff-competency expectations under 42 CFR §483.95 (Training Requirements) and the sufficient and competent staff requirement at 42 CFR §483.35, both of which surveyors lean on when the issue is not the procedure on paper but the staff's ability to execute it. [VERIFY: confirm F-Tag scope of F695 and that §483.25(i) is the current citation.]

The practical implication for an Administrator or DON is that you should not separate "what the procedure says" from "what staff can demonstrate." A surveyor is going to evaluate both, and a strong written procedure paired with a weak competency record is still a citation waiting to happen.

What a Complete Tracheostomy Care Procedure Should Cover

A complete written procedure should cover the equipment list, the technique itself, the frequency of routine care, the documentation expected after each episode, and what constitutes a deviation that must be reported to the charge nurse and provider. None of these five elements is optional. A procedure that lists only the steps, without telling staff how often the steps should occur or when to escalate, leaves the most important decisions to the bedside judgment of whoever is on shift — which is exactly what surveyors are trying to prevent.

Equipment. The procedure should specify the sterile and clean supplies needed for a routine care episode and should be explicit about which items are single-use and which are reprocessed per manufacturer instructions. A bedside emergency supply list should be separate and prominent — an obturator sized to the current tube, a spare tube in the same size and one size smaller, suction equipment ready to use, and a manual resuscitation bag with the appropriate connector are the categories that should always be at the bedside. [RN REVIEW: confirm the bedside emergency supply list matches current facility standards and is complete for your typical resident population.]

Technique. The procedure should describe inner cannula care, stoma site care, securement device assessment and change, and suctioning as discrete procedural elements with their own steps. Where a specific clinical parameter would normally be stated — for example suction catheter sizing, suction pressure setting, suction depth, or cuff pressure target — the procedure should reference the manufacturer's instructions for the specific tube in use and the resident's individualized care plan rather than hardcoding a single number that may not apply to every tube or every resident. [RN REVIEW: confirm your facility's practice on suction catheter sizing, suction pressure range, suction depth technique, and cuff pressure monitoring, and verify these are documented in the individual care plan rather than only in the generic procedure.]

Frequency. Routine care frequency should be stated in the procedure as a baseline (for example, inner cannula and stoma assessment at least once per shift) with clear language that the individualized care plan and provider orders may increase the frequency for a specific resident. Frequency that is set only on the care plan and absent from the procedure tends to drift over time as care plans turn over. [RN REVIEW: confirm baseline frequency language matches facility expectation.]

Documentation. Each care episode should generate a note that records the date and time, the staff member performing the care, the appearance of the stoma site, the character of secretions, any tolerance issues during the episode, and any communication to the charge nurse or provider. Documentation gaps are a primary surveyor finding pattern under F695 because they make it impossible to demonstrate that the care plan is being executed.

Escalation. The procedure should state in plain language what constitutes a finding that must be reported up — for example, new bleeding at the stoma, sudden change in secretion character, increased work of breathing, or any concern about tube position. The expectation should be that the charge nurse is notified during the episode, not at the end of shift.

Emergency Preparedness: What Has to Be in Place

Tube dislodgement and airway obstruction are the two emergencies every trach program has to be prepared for. This article will not publish a step-by-step emergency algorithm, because the right response depends on the type of tube, how mature the stoma is, whether the resident has had a laryngectomy (more on that in a moment), and your facility's specific protocol — and this is exactly the kind of content that has to live in your internal procedure where it can be tailored, kept current, and anchored to a training record. What I will say at the public level is that a strong program ensures four things are always true.

First, the bedside emergency supplies are present, sized correctly, and checked on a defined schedule. A spare tube attached to the wall in a sealed bag that hasn't been inventoried in six months is not preparedness.

Second, the staff caring for the resident know where those supplies are and have physically touched them. Reading a list on an in-service handout is not preparedness either. Competency checks should include a bedside walk-through where the staff member identifies and locates each item.

Third, there is a written, current emergency response procedure that the staff has been trained on, has acknowledged, and can be shown to a surveyor on request. The procedure should be specific about who is called, in what order, and through what means.

Fourth, every emergency event — including near-misses such as a partially dislodged tube that was repositioned without harm — is debriefed and tracked through QAPI. A facility that handles one trach emergency a year and never debriefs it learns nothing from it.

The Laryngectomy Distinction

A point that is worth its own section because it is the single most consequential misunderstanding I see in non-specialty settings: a tracheostomy and a laryngectomy are not the same thing, and the difference is not academic. A resident with a standard tracheostomy still has an intact upper airway — air can move through the nose and mouth, and in an emergency where the trach tube is lost, oxygenation through the mouth and nose remains anatomically possible. A resident who has had a total laryngectomy has had the larynx surgically removed; the stoma in the neck is the only airway. There is no anatomical connection between the mouth and the lungs. Attempting to ventilate or oxygenate a laryngectomy resident through the mouth or nose accomplishes nothing.

Facilities that accept laryngectomy residents need this distinction explicit in the resident's care plan, on the head of the bed, and in every staff member's competency record. [RN REVIEW: confirm the language used for laryngectomy bedside signage and care plan flagging in your facility.] This is the kind of detail that does not come up often, which is precisely why it has to be built into the standard procedure and the competency check rather than left to staff memory.

Why a Written Competency Checklist Matters for CMS

The CMS staff competency requirement is structural, not ceremonial. It is not enough to have a procedure on paper and a sign-in sheet from an annual in-service. Surveyors expect that facilities can demonstrate, for each staff member who performs tracheostomy care, that the staff member has been trained on the facility's specific procedure, that competency has been evaluated by direct observation, and that there is a dated record of that evaluation including who performed it and what was observed. [VERIFY: confirm the staff competency evidence expectations under §483.95 and §483.35 are stated accurately for current Appendix PP guidance.]

A useful competency checklist is structured around what staff actually does at the bedside. It is broken into discrete skills (suctioning, inner cannula care, stoma site assessment, securement device change, emergency supply identification, laryngectomy bedside flagging if applicable), each of which has an observable performance criterion. The observer initials each criterion as met or not met, and the date and observer name are captured at the bottom along with the staff member's acknowledgement. A checklist that says "demonstrated competency in trach care" with a single checkbox is not a competency record — it is a participation receipt.

For facilities that take vent-weaned or higher-acuity airway residents, the competency check should be repeated at a defined interval (annually at minimum, more frequently for new staff or after a near-miss event). The expectation is not perfection on first observation; the expectation is a documented training and re-training loop that closes around any observed gap.

Bringing It Together

A trach program that survives a survey has three things working together: a written procedure that is specific enough to be actionable but flexible enough to defer to manufacturer instructions and individualized care plans, an emergency preparedness baseline that is verifiable at the bedside and not just on paper, and a competency record that proves each staff member has been observed performing the procedure correctly. Most facilities have one or two of these. The work is making sure all three are present, current, and aligned with each other.

This is also the kind of program where the documentation burden is high enough that a lot of facilities never quite finish building it. The procedure exists but is outdated. The competency checklist exists for some staff but not others. The care plan references the procedure but the procedure doesn't reference the care plan. That gap is what we built Clinical Procedure Mode to close.

Paul Richards, RN, MSHI

Founder, EasyPOC

Paul Richards is a registered nurse and health informatics professional with years of experience in skilled nursing facility compliance and quality improvement. He built EasyPOC to solve the compliance documentation challenges he witnessed firsthand every day.