Failure to Provide Emergency Respiratory Support to Resident with Tracheostomy
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy, who had a history of acute respiratory failure with hypoxia and hypercapnia, bacterial pneumonia, morbid obesity, and tracheostomy status, experienced respiratory distress and did not receive appropriate respiratory support as ordered and required by their condition. The resident was admitted with a full code status and had physician orders for tracheostomy care every shift and as needed, continuous supplemental oxygen via trach, and as-needed nebulizer treatments for shortness of breath. The care plan failed to identify a plan for respiratory or tracheostomy care. On the day of the incident, the resident requested suctioning due to difficulty clearing secretions, which was performed by a nurse with assistance from another nurse. After suctioning, the resident requested to be changed and, during repositioning, began to complain of shortness of breath and showed signs of acute respiratory distress, including labored breathing and cyanosis. The oxygen flow was increased, but the resident showed no improvement. The nurse left the room to call 911 and prepare paperwork for transfer, while another nurse was to remain at the bedside. However, when EMS arrived, the resident was found alone, without supplemental oxygen, and in cardiac arrest. No CPR was being performed by staff prior to EMS arrival, and EMS personnel immediately initiated resuscitation efforts. Interviews and documentation revealed that during the emergency, staff did not administer the as-needed nebulizer treatment, did not attempt further suctioning, did not change the inner trach cannula, and did not use an Ambu bag to provide breaths. The resident's oxygen saturation had dropped to critically low levels, and the resident ultimately lost consciousness, lost respirations, and lost pulse, and was later pronounced deceased in the emergency room. The deficiency affected one of two residents reviewed for tracheostomy care.