Failure to Provide Physician-Ordered Tracheostomy Care and Equipment Changes
Summary
The facility failed to provide safe and appropriate respiratory care for a resident requiring tracheostomy care and tracheal suctioning, as ordered by the physician and consistent with professional standards of practice. Specifically, staff did not perform the prescribed trach care, including changing the trach aerosol tubing, mask, jet nebulizer bottle, water trap, and trach ties according to the schedule outlined in the physician's orders. Documentation in the Treatment Administration Records (TAR) for multiple dates showed that these tasks were not completed as required, and staff interviews confirmed that some care was either not performed or not documented. The facility's own policy required daily and PRN tracheostomy care using sterile technique, but this was not consistently followed. The resident involved had significant medical needs, including lymphoma, immunodeficiency, dysphagia, and a tracheostomy, and was dependent on staff for respiratory care. Observations and interviews revealed that the resident produced large amounts of thick mucus, required frequent suctioning, and was at increased risk for infection due to his immunocompromised status. Despite these needs, there were repeated failures to change respiratory equipment and trach ties as ordered, and staff could not consistently explain or document when or if these tasks were performed. The resident was eventually admitted to the hospital with brown emesis from the mouth and trach, and was diagnosed with MRSA bacteremia. Hospital staff noted that the trach had not been changed in a long time. Interviews with nursing and respiratory staff indicated a lack of clarity and follow-through regarding the completion and documentation of trach care. Some staff admitted to not documenting care, while others were unaware of discontinued orders or the reasons for missed care. The resident himself communicated that staff did not change the equipment as ordered, attributing it to staff not wanting to do the work. The DON was unaware of several missed or discontinued orders and did not follow up after the resident's hospital admission. These failures were identified through observation, interview, and record review, and resulted in an Immediate Jeopardy finding.
Removal Plan
- Identified resident was transferred to the hospital for further evaluation and treatment.
- The identified resident will be re-admitted if orders for such.
- Education will be completed regarding following physician orders for trach care to include changing trach aerosol tubing, mask, nebulizer bottle, water trap, trach ties and trach color as ordered.
- This education will be provided to current licensed nursing staff by the Director of Nursing/Respiratory Therapist and/or Regional Nurse Consultant.
- This training will be provided prior to staff working.
- Licensed staff will not provide direct care to residents until training is completed.
- Divisional Clinical Nurse reviewed facility's policy and procedures for tracheostomy care. No changes made.
- No new patients/residents requiring tracheostomy care/tracheal suctioning will be admitted until 100% of licensed staff have been trained and deemed competent.
- Two additional residents requiring respiratory/tracheostomy care and tracheal suctioning will be seen by the attending physician, or medical director to ensure no negative assessment findings.
- DON/Designee conducted an audit of current residents and tracheostomy supplies to validate trach supplies were available at bedside.
- The Director of Nursing will begin immediate in-servicing of LVN A, RN B, and LVN C, on the following: Completion and documentation of physician ordered tracheostomy care; Return demonstration of trach care w/competency documented.
- Licensed staff will ensure that the orders for trach care will include changing trach aerosol tubing, mask, nebulizer bottle, water trap, trach ties and trach collar as ordered.
- DON/designee will review MARs/TARs daily to validate trach care orders are carried out.
- LVN A, RN B, and LVN C staff will not be allowed to begin their shift until they have received the education/competency as noted above.
- Licensed weekend staff will be provided with 1:1 re-education on care for patients with tracheotomies. The education will include competency for tracheal care, suctioning, tubing changes, and documentation.
- The Director of Nursing, Assistant Director of Nursing or Regional Nurse Consultant will complete the following until substantial compliance has been met and achieved: Daily audits of residents requiring respiratory/tracheostomy care and tracheal suctioning will be reviewed to ensure that physician orders for such are documented.
- The facility will continue to provide the in-servicing as noted above to newly hired licensed staff, annually and as needed.
- The Director of Nursing or Assistant Director of Nursing will audit licensed nurses training and competency records to ensure tracheostomy care/tracheal suctioning training compliance.
- Nurse Managers will round on trach patients on weekends to validate trach care performed and there are no signs/symptoms of infection. Any issues identified will be addressed immediately.
- All components of this plan of correction will be submitted to the facility QAPI meeting and additional recommendations will be made until substantial compliance has been achieved.
- The Director of Nursing, Assistant Director of Nursing and Regional Nurse Consultant is responsible for the corrections and continued monitoring.
- The Medical Director was notified and agrees with the plan of removal.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Two residents receiving O2 had flow rates set above their physician orders, and one resident’s tubing remained dated beyond the weekly change interval. Staff, including an RN and the DON, confirmed the mismatched flow rates and noted that tubing should be changed weekly by the RT. The facility policy required O2 to be administered per physician order and tubing/cannula to be changed weekly.
Oxygen Concentrator Left in Room After Order Discontinued: A resident with morbid obesity with alveolar hypoventilation and diabetes was observed with an oxygen concentrator at bedside even though there was no current oxygen order. The resident stated he used oxygen only when needed, and the CNO confirmed the oxygen had been discontinued earlier and the concentrator should not have remained in the room.
Missing Order for CPAP Use and Maintenance: A resident with sleep apnea and stroke had a CPAP in the room, but there was no physician order or care plan documentation for its use or maintenance. Staff knew the resident had the CPAP, yet CNAs and an RN reported they did not routinely clean the mask or tubing, and the LPN Resident Care Manager confirmed no order existed for the CPAP or its care.
A resident with a continuous O2 order was found without oxygen in place, and an LPN later said the order had been misread. Two other residents with COPD had respiratory equipment that was dirty or outdated, including a gray concentrator filter, tubing and water bottles dated weeks earlier, and tubing lying on the floor with visible dust. Staff gave inconsistent accounts of who was responsible for changing or cleaning the equipment, and the DON acknowledged the dirty equipment and old mask placed residents at risk for respiratory infection or pneumonia.
A resident with acute respiratory failure with hypoxia and severe cognitive impairment was ordered oxygen via NC at 2 to 5 LPM to keep O2 saturation at or above 95%. During observation, the resident was lying in bed with the NC on the side of the face instead of in the nose while the concentrator was set at 2.5 LPM. RN and DON stated the NC should be in the nose to deliver oxygen as ordered.
A resident with COPD and chronic respiratory failure did not receive oxygen at the ordered flow rate. Staff found the oxygen concentrator set below the ordered amount on multiple observations, and the resident stated the oxygen was supposed to be set higher. The DON, LVNs, and ADON acknowledged the setting was incorrect and that the ordered flow should have been followed.
Incorrect Oxygen Flow Rates and Delayed Tubing Changes
Penalty
Summary
The facility failed to provide respiratory care consistent with physician orders for two residents receiving oxygen therapy. Resident #5 had an order dated 1/7/2025 for oxygen at 2 liters via nasal cannula continuously for infiltrate of the left lung, but during observations on 7/7/2026, 7/8/2026, and 7/9/2026 the resident’s oxygen was running at 3 liters per minute. On 7/7/2026 and 7/8/2026, the oxygen tubing in Resident #5’s room was dated 6/26, and on 7/9/2026 Staff F, RN confirmed the tubing date and the 3-liter flow rate. Staff F stated the tubing should have been changed the prior week and that the resident was running at 3 liters despite an order for 2 liters. Resident #6 had a physician order dated 3/18/2026 for oxygen at 3 liters via nasal cannula continuously for chronic respiratory failure with hypoxia, but during observations on 7/7/2026 at 10:10 AM and 12:12 PM, and again on 7/8/2026 at 8:02 AM, the resident’s oxygen was being administered at 4 liters per minute. On 7/9/2026 Staff F, RN entered the room and confirmed the oxygen was at 4 liters, stating it should not be at that rate because the order was for 3 liters. The DON stated nursing staff should check oxygen flow rate every shift and as needed, and that tubing should be changed weekly by the respiratory therapist. The facility policy also stated oxygen tubing and mask/cannula are to be changed weekly and as needed if soiled or contaminated.
Oxygen Concentrator Left in Room After Order Discontinued
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not maintained when the facility failed to remove an oxygen concentrator from Resident #12's room after the physician discontinued the oxygen order. Resident #12 was admitted and later readmitted to the facility with diagnoses including morbid obesity with alveolar hypoventilation and diabetes. On 7/7/26, the resident was observed sitting in his power chair with an oxygen concentrator at his bedside. When asked about oxygen use, the resident stated he only used oxygen when he needed it. Review of the resident's physician orders showed no current oxygen order, and the CNO stated on 7/8/26 that the oxygen concentrator should not have been in the room because oxygen had been discontinued on 6/17/26.
Missing Order for CPAP Use and Maintenance
Penalty
Summary
The facility failed to obtain physician orders for the use and maintenance of a CPAP for Resident 76, who was admitted in 6/2026 with diagnoses including sleep apnea and stroke. There was no documentation in the admission MDS or care plan showing that the resident used a CPAP. Observations from 7/6/26 through 7/10/26 showed the CPAP in the resident’s room on the nightstand. The resident stated that a friend brought the CPAP to the facility a day after admission, but staff did not clean the mask or tubing daily and the mask did not fit well. Staff interviews showed the CNA staff were aware of the CPAP but did not clean the mask or hose, one CNA reported washing the mask one time, and an RN stated she filled the chamber with water a few times but did not clean the mask or tubing. The LPN Resident Care Manager confirmed the resident did not have an order for the CPAP or for cleaning and caring for the equipment.
Respiratory Equipment Not Maintained or Applied as Ordered
Penalty
Summary
Resident #12 had an order for oxygen at 2 liters per minute via nasal cannula continuously, with titration up to 4 liters to keep oxygen saturations above 90% every shift. The resident’s care plan also directed staff to apply oxygen at 2 liters via nasal cannula. During an observation, the resident was up in a chair with no oxygen in place. The resident stated she had been wearing oxygen but was not sure when or why staff stopped applying it. The nurse later stated she had misread the order as oxygen could be applied only if saturations fell below 90%, and she acknowledged the resident did not wear oxygen despite the active continuous order. Resident #27 had diagnoses including dementia, COPD, anxiety, and shortness of breath, and her MDS indicated she required oxygen therapy. Her care plan directed staff to change oxygen tubing as needed and nebulizer tubing every week. During multiple observations, the resident’s oxygen concentrator filter was gray and dirty, and the tubing and empty water bottle were dated 5/24/26. The resident stated staff usually changed the equipment, but it had not been changed that she could recall. Later, the tubing and water bottle remained dated 5/24/26, and the concentrator filter was still dirty. Staff interviews reflected uncertainty about who was responsible for changing the equipment, and the ADON stated the tubing and water bottle should have been changed by 07/02/26, while the DON stated the dirty filter and old nebulizer mask placed the resident at risk for respiratory infection or pneumonia. Resident #9 had COPD and an order for oxygen at 2 to 4 liters per nasal cannula to maintain PO2 greater than 90%. The resident’s oxygen tubing was observed lying on the floor and had a piece of tape dated 06/22/26, with brown dust visible in the wheel-mark pattern on the tubing. The resident was unable to state when the tubing was last changed or how often it was changed. Staff interviews showed differing practices about changing oxygen tubing, with some stating it should be changed weekly or when dirty, while the DON stated she had been advised not to date the tubing and to change it when visibly soiled. The facility policy stated cannula or mask needed to be changed if it malfunctions or becomes visibly contaminated.
Oxygen Not Properly Delivered via Nasal Cannula
Penalty
Summary
The facility failed to ensure oxygen was administered in accordance with the physician’s order and facility policy for one sampled resident. Resident 44 was admitted with diagnoses including acute respiratory failure with hypoxia and encephalopathy. The MDS dated 5/28/2026 indicated the resident had severe cognitive impairment, was on oxygen therapy, and was dependent for eating, oral care, toileting, personal hygiene, showering, dressing, and footwear. A physician’s order dated 6/4/2026 directed oxygen via nasal cannula at 2 to 5 LPM to maintain oxygen saturation at or above 95% every shift, and the care plan was revised to reflect humidified oxygen via nasal cannula at 2 to 5 LPM to maintain oxygen saturation at or above 95% every shift. During a concurrent observation on 6/29/2026 at 10:33 AM, Resident 44 was observed lying in bed with the nasal cannula on the left side of the face while the oxygen concentrator was set at 2.5 LPM. During interviews, RN 3 stated the nasal cannula should be placed correctly in the resident’s nose for the resident to receive oxygen, and the DON stated the nasal cannula should always be in the resident’s nose to help maintain oxygen saturation at 95% and above. The facility policy titled Oxygen Administration stated oxygen is administered to residents who need it, consistent with professional standards of practice and comprehensive person-centered care plans, and under physician orders.
Incorrect Oxygen Flow Settings
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for a resident with COPD, chronic respiratory failure, and functional quadriplegia. The resident’s care plan directed that oxygen be administered at 2 L/min via nasal cannula continuously to maintain SPO2 above 90%, and the physician order summary reflected oxygen at 2 L/min via nasal cannula continuously. However, during observation and interview on 06/30/2026, the resident’s oxygen concentration machine was set at 3 L/min, and the resident stated her oxygen was supposed to be set at 4 L/min. The LVN stated the resident was supposed to be on 4 L/min and adjusted the oxygen to 3.5 L/min, and the DON later stated the resident was to be getting 4 L/min and adjusted the setting to 4 L/min. A subsequent physician order dated 07/01/2026 directed oxygen at 4 L/min via nasal cannula to maintain SPO2 above 90%. During observation on 07/02/2026, the resident’s oxygen was again found set at 3.5 L/min. An LVN checking the setting stated it was at 3.5 L/min and that if physician orders were not followed, the resident could become short of breath and the orders would not be followed. The ADON stated the oxygen machine should be set with the ball meter at eye level, that if the order said 4 L/min it should be set on 4 L/min, and that 3.5 L/min was not good enough. The facility’s oxygen administration policy required verifying a physician order and adjusting the oxygen delivery device so the proper flow of oxygen was being administered.
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