Failure in Tracheostomy Care Leads to Resident's Death
Summary
The facility failed to provide adequate tracheostomy care for a resident, leading to a critical incident. The resident, who had a history of cerebral infarction, tracheostomy, dysphagia, encephalopathy, and respiratory failure, experienced a partial displacement of their tracheal tube. Despite the intervention of a respiratory therapist who replaced the tube with a smaller size, the resident exhibited diminished breath sounds and minimal airflow, indicating respiratory distress. The situation escalated when the resident was found with breathing difficulties, unappreciated vital signs, and signs of cyanosis. The staff failed to promptly notify the physician or take appropriate actions to address the resident's change of condition. The paramedics were called but arrived to find the resident already deceased, with rigor and lividity present. Interviews with staff revealed a lack of communication and failure to follow protocols for notifying the physician and obtaining necessary medical imaging to confirm the tracheal tube placement. The staff did not adequately monitor the resident's condition or respond to the respiratory therapist's recommendations, contributing to the resident's deterioration and eventual death.
Removal Plan
- The DON provided one on one in-service education and COC competency to RN 1 regarding the proper procedures for assessing, identifying, and addressing a resident's COC, monitoring for any change of condition, and prompt notification of the physician to request for appropriate interventions for a COC.
- The DON and the Sub-Acute Unit RN 1 initiated in-service/education for all interdisciplinary staff regarding the proper procedures for identifying a resident's COC, reporting a COC, monitoring for any COC, and prompt notification of the physician to request for appropriate interventions for a COC. All decannulations or trach changes that require a smaller tracheal tube will be reported to the physician promptly for interventions.
- The DON and RN reviewed 15 residents' medical records with a change of condition. All documentation reflected that the physician was notified promptly regarding the change of condition as required.
- The DON and the Quality Assurance Consultant created a new COC Validation Competency which included recognizing signs and symptoms of respiratory distress, identifying a COC, notifying the physician regarding a COC immediately and documenting in the resident's medical record.
- All 43 residents with tracheostomy tubes were assessed by the respiratory therapist and no other residents were identified with abnormal findings. All residents had the proper trach size as ordered by the physician and no issues with tracheal tube placement. There were no residents with decannulation.
- The DON/Designee will randomly review at least 10 residents' medical records with COC charts per month for 3 months and then quarterly thereafter.
- The Director of Staff Development reviewed all RNs competencies to ensure completion. No other RNs were affected.
- RN 1 will receive and pass competency training monthly for 3 months and then annually thereafter. The DON/DSD/Designee will repeat in-service training monthly for 3 months and then quarterly and as needed regarding the proper procedures for identifying a resident's change of condition, reporting a change of condition, monitoring for any change of condition, and prompt notification of the physician to request for appropriate interventions for a change of condition, calling the paramedics in a timely manner during an emergency, and contacting the medical director if a physician does not answer.
- The DON/Designee will complete 10 competencies per month for IDT staff using the COC Competency and Validation form.
- Any negative findings of the residents' medical records audit will be reported by the Medical Records Director/Designee to the Quality Assurance Committee monthly for 3 months and then quarterly thereafter for review and further action as needed.
Penalty
Resources
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Surveyors found that a resident with chronic respiratory failure and a tracheostomy did not have an Ambu (resuscitation) bag readily available at the bedside, despite facility policy requiring a handheld resuscitation bag with oxygen source to be easily accessible for emergencies; the RN confirmed the bag was missing and would have to be obtained from a crash cart if needed. In addition, another resident receiving continuous oxygen therapy at 3 L/min via nasal cannula had no corresponding physician order, which was confirmed on record review and by an LPN in social services.
Two residents receiving continuous oxygen therapy did not receive care in accordance with physician orders or facility policy. One resident with sepsis and pulmonary hypertension had an order for 3 L/min via nasal cannula, but surveyors observed the concentrator set at 2 L/min, which an RN confirmed was inconsistent with the order. Another resident with COPD and acute respiratory failure had an order for 2 L/min and monthly tubing changes; surveyors observed the nasal cannula hanging on the bed with prongs pressed against the bed surface, not stored in a sanitary bag, and a CNA placed it on the resident without replacing it. Later, an RN was observed with the concentrator set at 2.5 L/min, above the ordered rate, and did not adjust it, despite a policy requiring oxygen to be given as ordered and equipment kept clean and sanitary.
A ventilator-dependent resident with a tracheostomy experienced an unrecognized and unmanaged decannulation during personal care when a CNA found the trach tube out and notified an agency LPN. The LPN, who reported having no orientation to the unit, no training on trach/vent care or decannulation procedures, and no knowledge of the location of emergency equipment, unsuccessfully attempted to reinsert the trach, then began chest compressions without providing supplemental O2 or using an Ambu-bag. When the RT and EMS arrived, they found the resident completely decannulated, dusky, and receiving compressions only; the RT reinserted the trach and initiated bagging with O2 while EMS continued CPR and transported the resident. EMS and hospital records documented that staff could not provide a history or send information with the resident, and hospital documentation and the death certificate attributed the subsequent cardiac arrest and death to hypoxic respiratory failure following trach dislodgement.
A cognitively intact, oxygen‑dependent resident with ESRD, paraplegia, and chronic respiratory failure was sent to dialysis with a portable oxygen tank that was not full. After dialysis, while waiting in the lobby for transportation, the tank from the facility became empty, and the resident became distressed until dialysis staff placed the resident on their oxygen concentrator. Dialysis staff repeatedly attempted to reach facility staff for a replacement tank, but the facility LPN stated they could not bring oxygen in time, and the transport company would not wait and had no portable oxygen. With the dialysis center closing and no portable oxygen available, the facility nurse instructed dialysis staff to call 911, and EMS transported the resident to the ED solely because the resident had run out of oxygen. EMS and dialysis staff reported this was a recurring issue, with the resident often arriving with insufficient oxygen to last through the return trip, and the facility’s oxygen policy did not address oxygen management for outside appointments.
A resident with multiple respiratory and cardiac diagnoses, including CHF, OSA, bronchiectasis, and chronic respiratory failure, had a care plan directing nightly BiPAP/CPAP use, but the facility lacked corresponding physician orders for the therapy and did not document nightly administration in the TARs, task worksheets, or nursing notes. The only related order was for weekly cleansing of the BiPAP mask. The resident’s family reported that CPAP had been ordered on admission and that the resident was not consistently using the device as ordered, nor was the family informed of refusals. The Administrator and DON confirmed the absence of necessary BiPAP/CPAP orders and documentation, resulting in a cited deficiency.
A resident with COPD, sleep apnea, and other comorbidities was repeatedly provided CPAP therapy and supplemental O2 without any corresponding physician orders, despite the care plan calling for oxygen as ordered by a physician. Clinical notes documented the resident on O2 via mask, CPAP, and nasal cannula on multiple occasions, and surveyors observed the resident using a CPAP set at 6 cmH2O with 2 L O2 at night. The resident and an LPN confirmed nightly CPAP and O2 use since admission, and the DON acknowledged that no physician orders for CPAP or O2 had been obtained, even though the facility’s oxygen policy required safe use.
Failure to Maintain Tracheostomy Emergency Equipment and Oxygen Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate respiratory and tracheostomy-related care and equipment for two residents. One resident, admitted with chronic respiratory failure with hypoxia, tracheostomy status, COPD, heart failure, and chronic pulmonary edema, had active orders for 28% humidified oxygen via tracheostomy collar to maintain oxygen saturation above 90%, with tracheostomy care every shift and a full code status. Her care plan identified risk for respiratory distress, decannulation, and infection, with interventions including humidified oxygen and tracheostomy care per orders and protocol. During an observation of tracheostomy care performed by an RN, the resident’s room was checked for emergency medical supplies related to her tracheostomy. All necessary emergency equipment was present except for an Ambu (resuscitation) bag, which could not be located despite the nurse searching the room. The RN acknowledged that an Ambu bag should be readily accessible in the room for emergencies and stated she would need to leave the room or have someone obtain one from the crash cart if needed. The facility’s tracheostomy care policy specified that a handheld resuscitation bag with attached oxygen source must be readily available for easy access in an emergency. The deficiency also includes the facility’s failure to ensure a physician’s order was in place for oxygen administration for another resident prior to its use. This resident was admitted with diagnoses including major depression and hypertension. An MDS assessment documented that the resident received continuous oxygen therapy. During an observation, the resident was noted to have oxygen in place at 3 L/min via nasal cannula. Review of current orders showed there was no physician’s order for the resident to receive oxygen. In a subsequent observation and interview, the resident was again seen resting in bed with oxygen in place, and a social services staff member, who is also an LPN, confirmed that there was no order in place for the oxygen therapy being administered.
Plan Of Correction
1. On 5/6/26, Director of Nursing verified an ambu bag at Resident #9's bedside. On 4/13/26 the Licensed Nurse contacted the physician and obtained an order for oxygen use for Resident #39. 2. Like Residents are identified as residents who utilize a tracheostomy within in the facility. Utilizing the Tracheostomy Care Audit tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of identified residents will be completed by the Director of Nursing or designee to ensure they have an Ambu bag at bedside. This audit along with identified corrections will be completed on or before 5/13/26. Like Residents are identified as residents who utilize oxygen within the facility. Utilizing the Respiratory Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of identified residents will be completed by the Director of Nursing or designee to ensure residents utilizing oxygen have physician orders for oxygen use in place. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Physician Orders, the emergency equipment to be at bedside for residents with a tracheostomy and the Use of Oxygen Policies to include obtaining physician orders for use of oxygen. This education will be completed on or before 5/13/26. 4. Utilizing the Tracheostomy Care Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit all residents with a tracheostomy weekly for four weeks, beginning 5/14/26 to ensure they have an Ambu bag at bedside. Noncompliance noted from audits will be corrected with emergency equipment at bedside for residents with a tracheostomy. Audits will be reviewed by Quality Assurance/Performance Improvement Committee for additional recommendations. Utilizing the Respiratory Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure residents utilizing oxygen have physician orders for oxygen use in place. Noncompliance noted from audits will be corrected with physician orders obtained for resident with oxygen use in place. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Follow Oxygen Orders and Maintain Sanitary Oxygen Equipment
Penalty
Summary
The deficiency involves the facility’s failure to provide oxygen therapy services according to physician orders and to maintain oxygen equipment in a sanitary condition for two residents. For one resident with sepsis due to MRSA and pulmonary hypertension, the MDS indicated continuous oxygen use and a physician order dated 3/11/26 specified oxygen at 3 L/min via nasal cannula continuously. On observation, the oxygen concentrator gauge showed delivery at 2 L/min while the resident was resting in bed. A concurrent interview with the RN present confirmed the oxygen was set at 2 L/min, and the RN further confirmed that the physician’s order required 3 L/min. The facility’s SOP for Administration of Oxygen directed staff to verify the physician’s order and to administer oxygen as ordered. For another resident with diagnoses including paroxysmal atrial fibrillation, GI hemorrhage, acute respiratory failure with hypoxia, and COPD, the admission MDS showed the resident was cognitively intact and receiving oxygen therapy. Physician orders dated 2/23/26 required oxygen at 2 L/min via nasal cannula continuously and monthly tubing changes. During observation, the nasal cannula was found hanging on the side of the bed, not stored in a sanitary bag, with the nasal prongs pressed against the side of the hospital bed. A CNA present then placed the same nasal cannula on the resident without replacing it and confirmed it should have been stored in a sanitary bag when not in use. A subsequent observation with an RN showed the oxygen concentrator set at 2.5 L/min, above the ordered 2 L/min, and the RN confirmed the discrepancy without making an adjustment. The facility’s oxygen administration policy required oxygen to be administered as ordered and equipment to be maintained in a clean and sanitary manner when not in use.
Failure to Provide Life-Sustaining Respiratory Care and Effective CPR After Tracheostomy Decannulation
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary life-sustaining respiratory services and effective CPR to a ventilator-dependent resident with a tracheostomy. The resident had diagnoses including acute and chronic respiratory failure, ventilator dependence, obstructive sleep apnea, pulmonary hypertension, and malnutrition, and was documented as a Full Code receiving invasive ventilation via a tracheostomy cannula. Her care plan included interventions to ensure trach ties were secured, to keep an extra trach cannula and obturator at the bedside, and a specific "cannula out" procedure directing staff to open the stoma with a hemostat, attempt reinsertion, monitor for respiratory distress, elevate the head of the bed, stay with the resident, and obtain medical help immediately if reinsertion was not possible. On the night of the incident, an agency LPN was assigned to the resident’s care. The LPN later reported she had not previously worked with the facility’s ventilator residents, had not been oriented to the unit or to the resident’s care plans, and had not received education on tracheostomy care, decannulation procedures, or the location of emergency equipment such as the crash cart and Ambu-bag. A CNA alerted the LPN that the resident’s trach had come out while care was being provided. When the LPN entered the room, she found the tracheostomy cannula lying on the resident’s chest and the resident unresponsive. The LPN attempted to reinsert the cannula but was unsuccessful, instructed the CNA to call the respiratory therapist and 911, and then began chest compressions when she could not obtain a pulse. During this period, the LPN did not provide supplemental oxygen and verified she did not know where the crash cart or Ambu-bag were located. The respiratory therapist, who had left the building at midnight after providing earlier trach and ventilator care and documenting that the resident was stable, was called back and arrived with EMS. Upon arrival, the respiratory therapist found the resident completely decannulated, very dusky, and with the LPN performing chest compressions but not providing oxygen via Ambu-bag or any other means. The respiratory therapist was able to reinsert the trach cannula, independently located the Ambu-bag in the gray basket on the ventilator, connected it to oxygen, and began ventilating the resident through the trach while EMS took over compressions. EMS documentation indicated that staff at the facility were unable to provide a history or information about the resident and that no information packet accompanied the resident to the hospital. Hospital records documented that the resident arrived in cardiac arrest secondary to hypoxic respiratory failure after the trach had been out for an undisclosed period of time, with initial blood gases showing respiratory acidosis and a clinical picture consistent with hypoxic respiratory failure leading to cardiac arrest. The death certificate listed anoxic brain injury secondary to cardiac arrest and hypoxic respiratory failure as the cause of death. Additional interviews and observations supported that staff were not adequately trained or prepared to manage tracheostomy emergencies. The agency LPN repeatedly told the respiratory therapist and EMS that she did not know where anything was for the resident or how to care for the trach when it became dislodged, despite having current CPR certification. The respiratory therapy manager confirmed there was no official training for agency nurses on caring for residents with tracheostomies on ventilators and stated that guidance was only contained in the care plans. A resident interview indicated awareness that a ventilator-dependent resident had died and that staff working that night were not trained to care for ventilator residents, and that there were no respiratory therapists in the building at night. Policy review showed that the facility’s CPR policy required provision of breaths via Ambu-bag after compressions, and the decannulation policy required calling 911, calling for a crash cart, attempting to reinsert the trach or establish an airway, and using an Ambu-bag with oxygen if there were no spontaneous breaths. Despite these written procedures and the presence of emergency supplies such as Ambu-bags and crash carts in the building, they were not effectively used during the resident’s decannulation and cardiac arrest, resulting in the identified deficiency.
Plan Of Correction
F695 On 10/05/25, Resident #54 was transferred to the hospital. On 10/05/25 at 6:00 A.M., Respiratory Therapist Manager (RTM) #242 verbally in-serviced both agency nurses, LPN #288 and LPN #302. Both nurses returned demonstration and reviewed printed policies and procedures in the agency binder after the incident occurred. This education included suctioning (both open and closed), how to measure the placement of the suction catheter, decannulation, how to use Ambu-bag and the competency checklist for respiratory nursing care for residents on ventilators and residents who have tracheostomy and the location of crash carts and Automated External Defibrillator (AED). On 10/07/25, CCO #300 and former Human Resource Manager (HRM) #303 in-serviced RNs and LPNs on Respiratory policies, CPR, supplemental oxygen, Trach and Decannulation. Policies and procedures were sent to all nurses via text message for immediate review. There was no documentation of receipt of the text to the staff.. On 10/07/25, CCO #300 and former HRM #303, in-serviced CNAs on personal care for residents with tracheostomies. Policies and procedures were sent to all CNAs via text for immediate review. There was no documentation of receipt of the text to the staff.. On 03/12/26 at 10:30 A.M., the Administrator and CCO #300 educated RTM #242 on the facility's requirements for nurses training for ventilator dependent residents, supplemental oxygen, tracheostomy care and emergency procedures. On 03/12/26 at 10:30 A.M., RTM #242 implemented an education binder to track and audit all facility and agency staff education documents. Beginning on 03/12/26 at 10:30 A.M., RTM #242 or designated Respiratory Therapist will train agency nursing staff on ventilator dependent residents care plans, protocols for tracheostomy care and emergency procedures for ventilator dependent and/or trach residents prior to providing care to residents. Competency checklist to be completed by Respiratory Therapist. This is a new standard practice going forward without an end date. On 03/12/26 at 10:45 A.M., RTM #242 re-educated and completed check-off on Competency Checklist for Respiratory Care for Nursing, Decannulation and Emergency Procedures for Registered Nurses (RNs) and LPNs. Education/Training included verbal, return demonstration and printed procedures. This was completed on 03/13/26. On 03/12/26 at 12:30 P.M., a Quality Assurance (QA) meeting was held immediately following notification of Immediate Jeopardy. This included CCO #300, the Administrator, LNHA, DON, Assistant DON, Minimum Data Set (MDS) Nurse, RTM #242, Infection Preventionist/Wound Nurse, Scheduler, Business Office Manager, Social Services, Activity Director, Maintenance Director, Dietary Manager, Therapy Manager, Housekeeping/Laundry Supervisor who met to discuss the 10/05/26 incident, education needed, policies and procedures to put into place. Beginning on 03/12/26 at 12:45 P.M., RTM #242 will complete a respiratory assessment for all at risk residents and ensure that residents are provided with respiratory care by trained staff. Completed by 03/13/26 at 4:00 P.M. Beginning on 03/12/26 at 1:30 P.M., the Director of Nursing (DON) and RTM #242, uploaded the acknowledgement procedure electronically to the Clipboard staffing agency to notify agency employees that our facility has vent/trach residents that require care outside of normal routine care. Agency staff must be trained by an RT on ventilator dependent resident care plans, protocols for tracheostomy care and emergency procedures for ventilator dependent residents and read and sign the Agency Nurse Binder at the nurse's station before starting their shift. This training will include verbal, return demonstration and printed procedures. Acknowledgement must be signed before the facility job positing applications will allow agency staff to pick up a shift at facility. DON verified posting on 03/13/26 8:05 P.M. On 03/13/26 at 3:00 P.M., RTM #242 completed Competency checklist and decannulation training for tracheostomy residents with Liberty Dialysis nurses. Training included verbal, return demonstration and printed procedures for respiratory needs of residents with tracheostomies. Completed on 03/12/26. Beginning on 03/12/26, LPN Scheduler #255, DON, and RTM #242 will attempt to schedule at least one facility licensed nurse trained by respiratory therapist per shift. LPN Scheduler #255 will notify DON and RTM #242 of any shifts that do not have a facility nurse trained by RT. In the unplanned event the facility would have two agency nurses working, the facility will have RT coverage or another licensed facility nurse in the facility who has completed training with a Respiratory Therapist for the duration of the shift. This will be ongoing practice, unless there are no residents with vents/traches in the facility. Beginning on 03/12/26, the DON or designated nurse manager and designated Respiratory Therapist will monitor schedule daily to ensure scheduling compliance with RTs and agency staff. Beginning on 03/13/26, the RTM #242 or designated Respiratory Therapist will monitor agency education binder daily to ensure all education documents are completed. This will be ongoing. Beginning on 03/13/26, the DON or designated nurse manager will audit the education binder weekly to ensure that Respiratory Therapist has trained all facility and agency staff. This will be ongoing. Beginning on 03/19/26 at 1:45 P.M., during the monthly Quality Assurance and Performance Improvement (QAPI) meeting with the Medical Director, a review of correction plan to ensure the training has been completed for all RNs, LPNs, agency and will be ongoing as needed. This will be reviewed at the quarterly QAPI meeting starting May 2026 and ongoing if the facility has residents that are ventilator dependent or have tracheostomy. Respiratory Department will provide additional training as needed outside of the regularly scheduled trainings. Beginning 04/01/26 and ongoing monthly, RTM #242 or the designated Respiratory Therapist will attend the monthly nurse and CNA meetings to provide ongoing education, review competency checklist and to ensure that staff are knowledgeable of policies and procedures related to residents on life sustaining mechanical devices and/or requiring CPR. This training will include verbal, return demonstration and printed procedures.
Removal Plan
- Transferred Resident #54 to the hospital.
- Respiratory Therapist Manager (RTM) #242 in-serviced agency nurses LPN #288 and LPN #302; both completed return demonstration and reviewed printed policies/procedures in the agency binder (suctioning open/closed, suction catheter placement measurement, decannulation, Ambu-bag use, respiratory nursing competency checklist for vent/trach residents, and location of crash carts/AED).
- Chief Compliance Officer (CCO) #300 and former Human Resource Manager (HRM) #303 in-serviced RNs and LPNs on respiratory policies, CPR, supplemental oxygen, trach care, and decannulation; policies/procedures were sent to all nurses via text message for immediate review.
- CCO #300 and former HRM #303 in-serviced CNAs on personal care for residents with tracheostomies; policies/procedures were sent to all CNAs via text for immediate review.
- Administrator and CCO #300 educated RTM #242 on facility requirements for nurse training for ventilator-dependent residents, supplemental oxygen, tracheostomy care, and emergency procedures.
- RTM #242 implemented an education binder to track and audit all facility and agency staff education documents.
- RTM #242 (or designated Respiratory Therapist) will train agency nursing staff on ventilator-dependent resident care plans, tracheostomy care protocols, and emergency procedures prior to providing care; Respiratory Therapist to complete competency checklist.
- RTM #242 re-educated and completed competency check-offs for RNs and LPNs on respiratory care, decannulation, and emergency procedures using verbal instruction, return demonstration, and printed procedures.
- Held a QA meeting with interdisciplinary team to discuss the incident, needed education, and policies/procedures to implement.
- RTM #242 will complete respiratory assessments for all at-risk residents and ensure respiratory care is provided by trained staff.
- DON and RTM #242 uploaded an acknowledgement procedure to the Clipboard staffing agency to notify agency employees that the facility has vent/trach residents requiring care beyond routine care.
- Required agency staff to be trained by an RT on ventilator-dependent resident care plans, tracheostomy care protocols, and emergency procedures and to read/sign the Agency Nurse Binder before starting shift; acknowledgement must be signed before agency staff can pick up a shift at the facility.
- RTM #242 completed competency checklist and decannulation training for Liberty Dialysis nurses caring for tracheostomy residents (verbal instruction, return demonstration, printed procedures).
- Scheduler, DON, and RTM #242 will attempt to schedule at least one facility licensed nurse trained by an RT per shift; scheduler will notify DON/RTM #242 of shifts without a facility nurse trained by RT.
- If two agency nurses are working unexpectedly, the facility will provide RT coverage or another licensed facility nurse who has completed RT training for the duration of the shift.
- Will not admit any resident with a tracheostomy or ventilator needs until an RT is present in the facility.
- Will not admit ventilator or tracheostomy residents off-hours or on weekends if an RT is not available.
- DON (or designated nurse manager) and RTM #242 (or designated RT) will monitor the schedule daily to ensure compliance with RT and agency staffing requirements.
- RTM #242 (or designated RT) will monitor the agency education binder daily to ensure all education documents are completed.
- DON (or designated nurse manager) will audit the education binder weekly to ensure a Respiratory Therapist has trained all facility and agency staff.
- During QAPI meeting with Medical Director, review the correction plan to ensure training completion for all RNs, LPNs, and agency staff; continue review at QAPI meetings while the facility has vent/trach residents.
- RTM #242 (or designated RT) will attend nurse and CNA meetings to provide ongoing education, review competency checklists, and ensure staff knowledge of policies/procedures for residents on life-sustaining mechanical devices and/or requiring CPR (verbal instruction, return demonstration, printed procedures).
Failure to Ensure Adequate Portable Oxygen for Oxygen‑Dependent Resident During Dialysis Transport
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate oxygen for a resident who was oxygen‑dependent during outside dialysis appointments. The resident had multiple diagnoses including end stage renal disease, paraplegia, acute and chronic respiratory failure with hypoxia, hypertension, type 2 diabetes, and psychosis, and used continuous oxygen via nasal cannula. Physician orders included dialysis three times weekly and continuous oxygen at five liters per minute via nasal cannula. The resident’s care plan identified the need for oxygen related to chronic respiratory disease and directed staff to observe for signs and symptoms of dyspnea. The facility’s oxygen administration policy addressed oxygen use under physician orders but did not address oxygen management for residents during appointments outside the facility. On the day of the incident, the resident completed dialysis treatment in the early afternoon and was placed back on the portable oxygen tank supplied by the facility while waiting in the dialysis center lobby for transportation back to the facility. Dialysis staff reported that the portable oxygen tank from the facility was not full and that the resident frequently arrived with insufficient oxygen to last through the return trip, often running out while waiting for transportation. On this occasion, while waiting in the lobby, the resident’s portable tank became empty, and he began complaining that he was not getting oxygen, became upset, crying, and exhibited distress such as huffing and puffing. Dialysis staff confirmed the tank from the nursing home was empty and placed the resident on the dialysis center’s oxygen concentrator, which improved his condition. Dialysis staff made multiple attempts to contact the facility to obtain a replacement oxygen tank. After several unanswered calls, they reached an LPN at the facility and explained that the resident’s tank was empty and he required oxygen. According to dialysis and EMS documentation, the facility nurse stated there was no way to bring a replacement tank in time, and transportation staff were unwilling to wait and did not have portable oxygen available. The dialysis center had only one E‑tank with the crash cart and otherwise used plug‑in concentrators, so they could not provide portable oxygen for transport. Following back‑and‑forth communication between dialysis staff and the facility nurse, and with the dialysis center closing and transportation leaving, the decision was made, with the facility nurse’s agreement, to call 911 and send the resident to the emergency department solely because he had run out of oxygen and no replacement tank was provided. EMS documentation and the resident’s own statements indicated that this was not the first time he had been sent out from the facility with a partially filled oxygen tank and had run out of oxygen while away from the facility. The EMS run sheet documented that EMS arrived to find the resident in the dialysis lobby on supplemental oxygen from the dialysis center’s concentrator, with oxygen saturation at 97% on oxygen. EMS noted that the resident was oxygen‑dependent at three liters per minute and that his portable tank from the facility had run out while he was waiting for his ride. EMS contacted the facility en route and were told again that staff had instructed dialysis to call 911 because the resident could not stay at the dialysis center and transportation would not wait. The emergency department after‑visit summary recorded that the resident was seen for running out of oxygen and that no emergency medical condition was identified at that time. In a later telephone interview, the resident reported that while at the facility he repeatedly ran out of oxygen because he was given “half‑tanks,” and he described being very upset when he ran out of oxygen at dialysis and transportation refused to take him without oxygen.
Failure to Implement and Document Ordered BiPAP/CPAP Therapy
Penalty
Summary
The facility failed to ensure that a resident’s BiPAP/CPAP therapy was implemented and documented according to physician recommendations and the resident’s care plan. The resident, who had diagnoses including congestive heart failure, obstructive sleep apnea, bronchiectasis, and chronic respiratory failure, was care planned on 05/18/22 as being at risk for altered respiratory status, with an intervention to assist in ensuring the BiPAP/CPAP mask was in place nightly per order. The quarterly MDS showed the resident had intact cognition and was receiving non-invasive oxygen therapy. However, review of physician orders from 08/11/22 through discharge on 10/14/25 revealed no physician order for BiPAP/CPAP therapy, aside from an order dated 05/04/24 directing staff to cleanse the BiPAP mask weekly on Sundays. Review of the resident’s medical record, including TARs, task worksheets, and nursing progress notes, showed no evidence that BiPAP/CPAP therapy was administered nightly as indicated in the care plan. The resident’s family representative reported that there had been an order for CPAP upon admission and stated the facility did not ensure the resident was using the CPAP machine as ordered, and that she was not informed when the resident refused the therapy. In an interview, the Administrator and DON confirmed that the medical record lacked documentation of BiPAP/CPAP administration and acknowledged there were no physician orders to administer it nightly, although there should have been. This deficiency was cited under Complaint Number 2705837.
CPAP and Oxygen Administered Without Physician Orders
Penalty
Summary
The deficiency involves the facility’s failure to obtain physician orders prior to administering CPAP therapy and supplemental oxygen to a resident. The resident was admitted with diagnoses including a stress fracture of the left femur, COPD, type 2 diabetes mellitus with complications, and morbid obesity. The care plan, initiated shortly after admission, identified altered cardiovascular and respiratory status related to hypertension, iron deficiency anemia, sleep apnea, and COPD, and included interventions to provide oxygen as ordered by a physician. The admission MDS documented that the resident was cognitively intact, required varying levels of assistance with ADLs, and used oxygen therapy. However, review of the physician orders revealed no orders for CPAP use or for oxygen administration. Despite this, clinical notes documented the resident on oxygen via mask, CPAP, and nasal cannula on multiple dates, with recorded oxygen saturations ranging from 90% to 96%. Surveyor observations showed a CPAP machine, oxygen concentrator, and portable oxygen tank present in the resident’s room, and on multiple mornings the resident was observed in bed with a CPAP mask in place, oxygen at 2 liters attached through CPAP tubing, and the CPAP set at 6 cmH2O. In interviews, the resident reported using the CPAP with 2 liters of oxygen every night since admission, and an LPN confirmed nightly use of CPAP and oxygen and acknowledged there were no physician orders for the CPAP setting or oxygen flow rate. The DON also confirmed that the resident had oxygen in the room and had not had physician orders for oxygen or CPAP use since admission. The facility’s oxygen policy stated that oxygen would be used in a safe manner, but the documented and observed use of CPAP and oxygen occurred without corresponding physician orders.
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