Failure to Provide Adequate Tracheostomy Care
Summary
The facility failed to provide adequate respiratory care for two residents requiring tracheostomy care, leading to significant deficiencies. One resident, a female with a history of cardiac arrest, cerebral infarction, pneumonia, and pulmonary edema, experienced respiratory distress due to an obstructed tracheostomy inner cannula. Despite attempts to suction, the obstruction was not cleared, resulting in the resident's hospitalization and subsequent death. The medical director indicated that standard practice would involve removing the inner cannula to check for obstructions, which was not done in this case. Another resident, a male with acute and chronic respiratory failure and pneumonitis, also did not receive proper tracheostomy care. The facility lacked full-time qualified staff to perform necessary tracheostomy care, relying instead on a respiratory therapist who was only available on a PRN basis. The Director of Nursing stated that nurses were not permitted to remove or change cannulas, which contradicted the expectations set by the Regional Nurse, who indicated that nursing staff should be able to perform such tasks for certain types of tracheostomies. These failures resulted in the identification of an Immediate Jeopardy situation, as the facility did not ensure that residents received care consistent with professional standards. The lack of proper tracheostomy care placed residents at risk for serious harm, impairment, or death, highlighting significant deficiencies in the facility's ability to provide necessary respiratory care and services.
Removal Plan
- Nursing staff will be in-serviced to respond to medical emergencies for residents, when their tracheostomy becomes clogged, a mucus plug is identified, or resident is having difficulty breathing.
- Resident #2 will be provided for appropriately, with having all nurses trained in decannulation/re-cannulation of tracheostomy, in the case of a mucus plug/blockage, by the facility respiratory therapist, or by the Director of Nursing, who will be trained by the facility respiratory therapist.
- The Director of Nursing, Clinical Support Specialist, and VP of Clinical Operations will deliver all following in-service education to nurses one on one. All nursing staff will be in-serviced prior to them arriving to the facility for their next shift. Competency with return demonstration will be completed.
- The DON will review new hire orientation packet to ensure these above in-services are completed prior to the first shift on the floor, including tracheostomy competencies including decannulation/re-cannulation emergency procedures.
- Facility policy was updated to reflect decannulation and re-cannulation of tracheostomy is necessary in an emergency situation where the airway is compromised by a mucus plug, and the suction catheter meets resistance.
- Physician orders added to each resident with a tracheostomy, to include, may decannulate and re-cannulate tracheostomy if unable to establish patent airway or mucus plug present, per LVN/RN.
- Resident orders updated to include a tracheostomy one size smaller to be included in emergency supply box at bedside.
- The 24-hour report in the EMR which runs all progress notes in real time, will be monitored daily in the clinical meeting for changes in condition by the clinical team, DON/ADON/MDS.
- The DON or designee will perform random in person audits with nursing staff to ensure they understand the tracheostomy decannulation/re-cannulation procedure.
- DON/ADON's will make rounds daily, the weekend RN supervisor will round on all residents on the weekend, on all residents in facility to ensure no changes in condition are in progress regarding trach status.
- The Director of Nursing and VP of Clinical Operations viewed each resident with a tracheostomy to ensure all emergency supplies were present at bedside.
- An interim QAPI committee meeting was completed.
- IDT will review for compliance monthly in QAPI.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
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.
The facility failed to safely manage and provide oxygen therapy for two residents. One resident with COPD and chronic respiratory failure had an oxygen concentrator running at 2 L/min with undated nasal cannula and mask tubing lying on the floor, contrary to facility policy requiring dated tubing and proper storage. Another resident with chronic respiratory failure, CKD stage 5, CHF, and OSA, ordered for continuous oxygen at 2 L/min, was observed in the dining room with an undated nasal cannula connected to a portable oxygen tank whose gauges indicated it was empty; the resident reported increased shortness of breath, and staff confirmed the empty tank and lack of dating. Facility respiratory equipment and oxygen administration policies requiring dating and appropriate handling of oxygen tubing were not followed.
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.
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.
Failure to Safely Manage and Provide Oxygen Therapy
Penalty
Summary
The facility failed to ensure safe storage and dating of respiratory supplies and timely, sufficient provision of supplemental oxygen for two residents. For one resident with chronic obstructive pulmonary disease and chronic respiratory failure, a quarterly MDS showed intact cognition and a need for oxygen therapy, and the care plan identified potential complications related to respiratory disease and oxygen use. During observation, the resident’s oxygen concentrator was running at two liters with undated tubing attached to a nasal cannula lying on the floor in front of the concentrator, and additional undated tubing with an oxygen mask was also lying on the floor. An LPN confirmed that the undated tubing, nasal cannula, and oxygen mask were on the floor. For another resident with chronic respiratory failure with hypoxia, stage five chronic kidney disease, chronic heart failure, and obstructive sleep apnea, the quarterly MDS indicated intact cognition, dependence for transfers and mobility, need for assistance with ADLs, cardiorespiratory diagnoses, and use of oxygen therapy. Physician orders required continuous oxygen at two liters per minute via nasal cannula. Observation found the resident in the dining room wearing an undated nasal cannula connected to a portable oxygen tank set at two liters per minute, with both gauges on the tank indicating it was empty. The resident reported increased shortness of breath since awakening that morning and continued shortness of breath at the time of interview. A CNA confirmed the nasal cannula was not dated and the portable tank gauges showed the tank was empty. Facility policies required monthly changes of oxygen cannula and tubing, storage in a plastic bag when not in use, and dating of oxygen tubing, which were not followed in these instances.
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