Failure to Follow Change of Condition Protocols Leads to Resident's Death
Summary
The facility failed to ensure that a registered nurse (RN) had the necessary skills and knowledge to provide appropriate care to a resident experiencing a change of condition. The resident, who had a tracheostomy and was at risk for respiratory distress, experienced a tracheal tube displacement. A respiratory therapist (RT) replaced the tube with a smaller size, resulting in diminished breath sounds and minimal airflow. Despite being advised to notify the medical doctor (MD) for further intervention, the RN did not secure an order for an x-ray to confirm the new tube placement or notify the MD promptly. Later, the resident was found with breathing difficulties and unappreciated vital signs. The RN delayed calling emergency services, waiting six minutes before contacting paramedics. Upon arrival, the paramedics found the resident with signs of rigor and lividity, and the resident was pronounced dead shortly after. Interviews revealed that the RN did not follow the facility's policy for change of condition and cardiopulmonary resuscitation, which required immediate notification of the physician and emergency services. The resident had a history of cerebral infarction, tracheostomy, dysphagia, encephalopathy, and respiratory failure. The care plan indicated the need for special tracheal tube care and prompt notification of the physician in case of decannulation or respiratory distress. The RN's failure to act according to the facility's policies and procedures contributed to the resident's decline 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
Below are regulatory guidelines relevant to this citation:
The facility failed to ensure adequate RN or RT coverage for two ventilator-dependent residents whose care plans and orders required frequent ventilator checks, trach care, suctioning, HME and circuit changes, and close monitoring of respiratory status. On at least one night shift, only LPNs were on duty with no RN or RT present, despite these residents’ dependence on mechanical ventilation and tracheostomies. The DON acknowledged there was no RN or RT on that shift, believed prior daytime RN presence met requirements, allowed LPNs to perform ventilator care without certification or documented competency, and was unsure whether such care was within LPN scope of practice. Cited literature from the National Library of Medicine noted that mechanical ventilators are complex, require specific training, and are best managed by RTs, with improper management linked to poor outcomes.
A resident with a PICC line for IV cefepime therapy and multiple comorbidities received IV medication from an LPN who attached IV tubing directly to the open end of the PICC line without a needleless connector, after cleaning only the open hub. The LPN stated that PICC lines do not have valves, despite reporting prior IV therapy training. Facility leadership and HR reported they did not maintain competency or training records for agency staff, and one agency only verified licensure while another provided a self-assessment showing the LPN rated IV skills as limited and requiring supervision, even though the facility’s contract assigned responsibility for orientation, education, and competency of agency staff to the facility.
A staff member was hired and worked in the capacity of a CNA for an extended period without ever obtaining CNA certification or being listed on the Nurse Aide Registry. HR records and interviews showed that the individual completed two Nurse Aide Training classes and repeatedly failed the written competency test, yet was still permitted to perform CNA duties and provide direct care to residents. The personnel file contained only training completion certificates and no verification of an active CNA certification or registry check, affecting care provided to all residents in the facility.
A CNA transferred a resident with cognitive and physical impairments using a mechanical lift without a second staff member present and without having received proper training on the equipment, in violation of facility policy requiring two trained staff for such transfers.
A resident with complex medical needs did not receive prescribed IV vancomycin through a PICC line because no RN was available to administer the medication. The medication was delivered, but scheduled doses were missed due to the absence of qualified staff, despite facility policy requiring timely administration of medications.
Two residents with midline IV catheters for UTI treatment had their catheters removed by an LPN who lacked documented training and was not qualified under state regulations or facility policy to perform this procedure. Staff interviews and record reviews confirmed that the LPN did not have the required competencies, and there was confusion among staff about the scope of LPN practice regarding midline IV removal.
Insufficient Qualified Nursing and Respiratory Staff for Ventilator-Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient qualified RNs or RTs were available to care for residents requiring ventilator support. Resident #1 was admitted with sepsis, pneumonia, and acute and chronic respiratory failure with hypoxia and had physician orders for ventilator checks every four hours and as needed, tracheostomy care every shift and as needed, suctioning via trach as needed, and daily HME changes. Care plans for Resident #1 documented dependence on a ventilator and tracheostomy, with goals to maintain adequate oxygenation and be free from respiratory distress, and interventions including monitoring lung sounds and oxygen levels, providing respiratory treatments and oxygen as ordered, and ensuring ventilator settings were correct. Resident #2 was admitted with anemia, ventilator dependence, and functional quadriplegia, and had care plans indicating alteration in respiratory function related to respiratory failure, tracheostomy, ventilator use, and a history of aspiration pneumonia and mucus plugging. The care plans for Resident #2 included goals to remain free from respiratory distress and maintain oxygen levels at provider-set targets. Interventions required included ventilator checks every four hours, AVAP per physician order, tracheostomy tube changes every 30–45 days by an RT, regular changes of ventilator circuits, HMEs, inner cannulas, trach ties, and nebulizer setups, as well as suctioning, CPT, aerosol treatments, and close monitoring of lung sounds, oxygen levels, and signs of dyspnea. Review of staffing schedules for a specified week showed that on one night shift there were three LPNs on duty and no RTs or RNs present, despite the presence of two ventilator-dependent residents. In an interview, the DON confirmed that there was no RN or RT on that night shift and stated he believed that having an RN in the building earlier in the day met requirements and that LPNs could care for ventilator residents based on education and observation, even though they had no certification or documented return demonstration. The DON also stated he was unsure whether ventilator care was within the LPN scope of practice. Literature from the National Library of Medicine cited in the report emphasized that mechanical ventilators are sophisticated devices requiring specific training, that inappropriate management can result in poor patient outcomes, and that RTs are best suited to manage and adjust ventilators, underscoring the need for appropriately trained personnel.
Failure to Ensure Competent IV Therapy Administration by Agency LPN
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an IV medication was administered by a competent licensed nurse and to verify and document IV therapy competencies for an agency LPN. A resident was admitted with a postoperative wound infection, a PICC line placed in the right upper arm for long-term IV antibiotic therapy, and multiple comorbidities including diabetes, liver disease, hypertension, anemia, depression, and a history of stroke. The resident had an order for IV cefepime 2 g in 100 ml normal saline to be given three times daily via the PICC line. On observation, the PICC line had a flesh-colored bandage wrapped around the base, obscuring the insertion site, and the external catheter had a purple open-ended hub labeled “5 ml” with no needleless connector/valve attached. During administration of IV cefepime, the LPN cleaned the open end of the external PICC with an alcohol swab, flushed with normal saline, and then attached the IV tubing directly to the open end of the PICC line without a needleless connector device. When questioned, the LPN stated that PICC lines she worked with never had valves and that this was how PICC lines are, despite reporting that she had IV therapy training and certification. Licensure review showed the LPN had been licensed less than a year and, per the Ohio Board of Nursing, IV certification is no longer listed on LPN licenses for those licensed after a certain date, making IV training and competency verification the employer’s responsibility. The Human Resource Director reported she did not maintain personnel files, licensure checks, or competency records for agency staff, and the interim DON reported having no education or competency documentation for the LPN other than IV training provided after the issue was identified, stating that the agency would have competency records. The Administrator reported that one staffing agency only verified licensure and did not check competencies, and that another agency provided only a self-assessment skills checklist on which the LPN rated her IV therapy skills as limited and requiring supervision. The facility’s contract with that agency specified that the facility was responsible for orientation, education, training, and competency of agency staff.
Uncertified Staff Member Allowed to Perform CNA Duties
Penalty
Summary
The facility failed to ensure that a staff member working as a CNA met state and federal requirements before providing direct resident care. Human Resources records and interviews showed that this individual was hired as a CNA and provided care to residents for approximately 17 months without ever obtaining CNA certification or being listed on the Nurse Aide Registry. The HR Director reported that the staff member completed an initial Nurse Aide Training class and repeatedly attempted the CNA test but failed the written portion multiple times, then missed a subsequent test and was required to retake the entire training. After completing a second Nurse Aide Training class, the staff member again failed the written test and never achieved certification. Despite this, the facility allowed the individual to continue performing CNA duties and providing care to residents throughout the facility. Review of the personnel file confirmed only certificates of completion for two Nurse Aide Training classes and no documentation of a Nurse Aide Registry check or active certification. This deficiency was identified through personnel record review and staff interviews and was associated with complaint investigations, with the facility census noted as 60 residents at the time of the survey. The report states that this failure had the potential to affect all residents residing in the facility.
Failure to Train Staff on Mechanical Lift Use and Adherence to Transfer Protocols
Penalty
Summary
The facility failed to ensure that staff were properly trained and demonstrated competency in the use of mechanical lifts, as required by facility policy. Observation revealed that a Certified Nursing Assistant (CNA) attempted to transfer a resident with dementia, muscle weakness, and impaired balance from bed to wheelchair by pulling the resident to a standing position multiple times before resorting to a mechanical lift. The CNA then used the mechanical lift to transfer the resident without the assistance of a second staff member, contrary to the facility's policy that mandates at least two staff for such transfers. Interviews with the CNA and the Administrator confirmed that the CNA had not received training on the use of mechanical lifts upon hire and that two staff should be present during mechanical lift transfers. The facility's policy also requires staff to be trained and demonstrate competency with the specific equipment used. The deficiency was identified during a review of residents dependent on mechanical lifts, affecting one resident directly observed and potentially impacting others.
Failure to Provide Qualified Staff for IV Medication Administration via PICC Line
Penalty
Summary
The facility failed to ensure that qualified staff were available to administer intravenous (IV) medication through a Peripherally Inserted Central Catheter (PICC) line for a resident who required this level of care. The resident, who had diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, and Crohn's disease, was admitted and later readmitted to the facility. Following a hospital visit for a urinary tract infection, the resident was discharged with a new order for vancomycin IV to be administered every twelve hours via a PICC line. The medication was delivered to the facility, but was not administered as ordered. Documentation and staff interviews revealed that the doses of vancomycin scheduled for administration were missed because there was no Registered Nurse (RN) available to initiate the medication through the PICC line. The Director of Nursing (DON) confirmed that she was the only RN on staff and was not present to administer the medication, and the Assistant Director of Nursing (ADON) was no longer employed at the facility. Facility policy required that medication be administered without unnecessary interruptions and in accordance with prescriber orders, but this was not followed due to the lack of qualified staff.
Unqualified LPNs Removed Midline IV Catheters
Penalty
Summary
The facility failed to ensure that only qualified personnel removed midline intravenous (IV) catheters for two residents who had received IV therapy for urinary tract infections. Both residents were cognitively intact and had midline IV catheters placed at the facility by an outside specialty nursing service. After completion of their IV antibiotic courses, a Licensed Practical Nurse (LPN) removed the midline IV catheters for both residents, despite lacking documented training or qualifications specific to midline or peripherally inserted central catheter (PICC) procedures. Review of the LPN's personnel file showed only basic IV training certification from 2014, with no evidence of midline or PICC-specific training. Facility policy and the Ohio Administrative Code specify that LPNs are not permitted to initiate or discontinue a PICC or any catheter longer than three inches, which includes midline catheters. Interviews with facility staff and the Regional Director of Clinical Services (RDCS) confirmed that the LPN was not qualified to remove the midline IV catheters and that there was confusion among staff regarding the scope of practice for LPNs in this area. The deficiency was identified through record review, staff and resident interviews, and policy review, which collectively demonstrated that the facility did not ensure nurses and nurse aides had the appropriate competencies to care for residents with midline IV catheters. The RDCS acknowledged a lack of IV training for staff and was unaware of the specific state regulations prohibiting LPNs from removing midline catheters. Both residents reported no discomfort or issues following the removal, but the removals were performed by unqualified personnel in violation of state regulations and facility policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
