Failure to Provide Proper CPR for Residents with Tracheostomies
Penalty
Summary
The facility failed to provide Cardiopulmonary Resuscitation (CPR) according to accepted professional standards for two residents with tracheostomies who were full code status. In both cases, staff did not provide adequate respiratory ventilation through the residents' primary airway, the tracheostomy, during resuscitation efforts. Instead, staff attempted to provide ventilation via the mouth or did not provide ventilation at all, despite the presence of bag valve masks (BVMs) in the room, which were not compatible with the tracheostomy or staff did not know how to use them properly. For the first resident, who had chronic obstructive pulmonary disease, asthma, and a tracheostomy, staff initiated CPR after the resident was found unresponsive and cyanotic. However, they were unable to attach the BVM to the tracheostomy and instead covered the tracheostomy with a gloved hand and attempted to bag via the mouth, ultimately providing only chest compressions without ventilation. For the second resident, who had anoxic brain damage, paraplegia, respiratory failure, and a tracheostomy, staff also failed to ventilate through the tracheostomy. Staff attempted to bag via the mouth, not realizing the need to ventilate through the tracheostomy, and were unfamiliar with the correct procedure and equipment. Interviews with staff revealed a lack of knowledge and training regarding CPR for residents with tracheostomies, as well as issues with equipment availability and compatibility. The facility's own policies required that residents with tracheostomies receive care to maintain a patent airway and that CPR be performed per BLS guidelines, but these were not followed. Both residents died following these events, and the failures were confirmed through interviews, record reviews, and observations by surveyors.
Removal Plan
- Staff were inserviced on performing CPR on residents with tracheostomies
- CPR Policy was reviewed
- CPR equipment was verified as available in the Facility
- CPR audits were initiated
- QAPI Meeting was held