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:
Missing Oxygen Order and Improper Nebulizer Storage: A resident receiving oxygen for sleep apnea had no physician order specifying the oxygen delivery rate, even though staff were setting the rate. In a separate observation, a resident’s nebulizer mask was left unbagged on the nightstand while not in use. An LPN and the DON both stated respiratory equipment should be stored in a bag when not in use, and the facility policy required bagged storage between uses.
Respiratory care was not provided in accordance with standards for several residents receiving oxygen and nebulizer treatments. Staff observed outdated oxygen tubing and humidification equipment, a nebulizer mouthpiece left out with tubing touching the floor, and oxygen supplies not stored properly. One resident’s oxygen was running at a higher flow than ordered, and staff confirmed the tubing and humidification items should be changed weekly and documented.
Improper Storage and Dating of Oxygen and CPAP Equipment: Two residents had oxygen equipment and CPAP items observed out of proper storage, including nasal cannula tubing on the floor, undated or empty humidifiers, and a CPAP mask on the floor. One resident had OSA with an order for oxygen at bedtime and as needed, and the other had COPD with orders for nightly CPAP and continuous oxygen. Staff stated the tubing, humidifier, and CPAP mask should be stored and dated per facility practice, and the facility policy required weekly changes and dating of oxygen equipment.
A resident receiving continuous O2 via nasal cannula had the cannula found on the floor while the concentrator was running. A CNA placed the cannula back on the resident’s face before an LVN identified it as contaminated and replaced the cannula and tubing. The resident had diagnoses including hypertensive heart disease and atherosclerotic heart disease, and the care plan called for O2 at 2 L/min to maintain O2 sats above 92%.
A resident with COPD, a respiratory infection, continuous O2, and CPAP therapy had CPAP and nasal cannula tubing observed lying on the bed and the CPAP mask draped over the machine instead of being stored in a sanitary container. Staff interviews showed inconsistent understanding of how to store the respiratory equipment, and the facility did not provide the requested storage of the equipment when not in use.
Respiratory equipment was not properly changed, labeled, or stored for a resident receiving nebulizer treatment. An undated aerosol mask attached to a nebulizer was observed on the resident’s nightstand, open to air, and remained there on a later observation. An LPN confirmed the mask was open to air and not stored properly, and the DON confirmed the mask and tubing had not been dated or stored properly.
Missing Oxygen Order and Improper Nebulizer Storage
Penalty
Summary
The facility failed to ensure that Resident #11’s oxygen delivery rate was specified in the clinical record. Resident #11 was observed semi reclined in bed receiving oxygen from a concentrator via nasal cannula at 2 liters per minute. The resident’s care plan, initiated 1/2/2026, identified risk for complications related to sleep apnea and included oxygen as needed to promote lung expansion and improve air exchange, with positioning at 45 degrees if tolerated. The physician orders included oxygen-related maintenance and respiratory orders for oxygen at night for sleep apnea, but the clinical record did not contain a physician’s order establishing the ordered oxygen delivery rate. An LPN confirmed the record did not show an ordered delivery rate, and the DON agreed the oxygen delivery rate should be included as a physician’s order. The facility also failed to ensure nebulizer equipment was properly stored for Resident #85. During observations, a nebulizer mask was seen lying on top of the nightstand and was not bagged while the resident was sitting in a wheelchair and later while lying in bed with eyes closed. Resident #85 had physician orders for levalbuterol nebulization every 8 hours and ipratropium-albuterol inhalation solution every 6 hours as needed for shortness of breath. An LPN stated the nebulizer mask and oxygen tubing should be stored in a bag when not in use, and the DON stated the nebulizer mask and tubing should be stored in a dated bag when not in use. The facility policy stated oxygen cannula and tubing used PRN should be kept in a plastic bag when not in use, and nebulizer circuits should be stored in a plastic bag marked with the date and resident’s name between uses.
Respiratory equipment was not maintained and stored per standards
Penalty
Summary
The facility failed to follow professional standards of practice for oxygen and nebulizer treatments for four residents receiving respiratory services. During observations, Resident #56 was receiving continuous oxygen at 4 liters per minute by nasal cannula, and the tubing was dated 5/22 even though staff stated the tubing should be changed weekly on Thursdays. The DON confirmed oxygen tubing is changed weekly. Resident #56’s physician order dated 4/2/2026 ordered continuous oxygen at 4 liters nasal cannula. Resident #29 was observed with oxygen via nasal cannula connected to an oxygen concentrator with a humidification/water bottle dated 5/17/26, and the same date was observed again the next day. Her orders included continuous oxygen at 2 liters and weekly change of tubing, mask, and/or nasal cannula, but there was no order for humidification related to her oxygen and no MAR/TAR entry for humidification. Staff stated the humidification bottles should be changed weekly and at the same time as the tubing, and the DON stated there should be an order for humidification and that tubing and humidification bottles should be documented on the TAR. Resident #55’s nebulizer setup was observed with inhalation tubing hanging from the machine, with the distal tip touching the floor, and the mouthpiece sitting on the bedside table instead of in a plastic storage container. Resident #88 was observed with an oxygen concentrator running at 4.5 liters per minute, while the physician order was for 2 liters continuous; the oxygen cannula was wrapped around the bedside rail and not stored in a bag. The unit manager stated oxygen supplies should be stored in a dated plastic bag and the mouthpiece should not be left on the bedside table.
Improper Storage and Dating of Oxygen and CPAP Equipment
Penalty
Summary
The provider failed to ensure infection control practices were followed for oxygen equipment for two residents. One resident had obstructive sleep apnea and an order for oxygen at 3 L by nasal cannula at bedtime and as needed; observations showed the nasal cannula tubing on the floor and not dated, and the pre-filled humidifier was not dated. The resident’s June 2026 TAR did not indicate when the nurse was to change the oxygen tubing. Another resident had COPD and orders for nightly CPAP use and continuous oxygen at 2 L. Observations showed the oxygen concentrator in the room, the nasal cannula tubing dated but later found on the floor, the pre-filled humidifier empty and not dated, and the CPAP mask on the floor between the bed and nightstand. Staff interviews stated the oxygen tubing should be stored in a bag or in the bedside table drawer when not in use, the CPAP mask should be stored on the CPAP machine, and the tubing and humidifier should be dated when changed. The facility policies stated oxygen tubing and nasal cannula/mask were to be changed weekly, the tubing should be changed when found lying on the floor, and the humidifier bottle should be replaced weekly and as needed with date and initials.
Contaminated oxygen tubing was placed back on a resident
Penalty
Summary
Resident #7, a female admitted on 05/14/2026 with diagnoses including hypertensive heart disease and atherosclerotic heart disease, was ordered to receive oxygen at 2 L/min via nasal cannula continuously every shift. Her MDS indicated that she was rarely/never understood and received oxygen therapy, and her care plan addressed impaired gas exchange related to respiratory failure with oxygen at 2 L/min via nasal cannula to maintain O2 saturations above 92%. During observation on 06/01/2026, Resident #7 was in bed with the head of bed elevated about 30 degrees. The oxygen concentrator was running at 2 L/min, but the tubing was above her head and the nasal cannula was lying on the floor. CNA C picked up the cannula from the floor and placed it back on the resident’s face. LVN A then entered the room and stated the cannula was contaminated and immediately changed it out. CNA C stated she had put the cannula back on because she did not think it had touched the floor, but also acknowledged that it could be contaminated and cause infection if it touched the floor. LVN A stated the cannula and tubing were changed because they had touched the floor and were contaminated. The DON stated the expectation was that tubing or a nasal cannula on the floor are to be changed out to prevent infection.
Respiratory Equipment Not Stored Sanitarily
Penalty
Summary
The facility failed to provide adequate respiratory care and services for a resident with COPD, diabetes mellitus, major depressive disorder, and neuromuscular dysfunction of the bladder who also had a respiratory infection and was receiving continuous oxygen and CPAP therapy. The resident’s MDS documented intact cognition, lower-body extremity impairment, and dependence on staff for toileting, bathing, and dressing, with setup or cleanup assistance needed for eating and oral hygiene. The care plan and physician orders directed staff to assist with CPAP application every bedtime, ensure oxygen was connected at 3 L/min, clean the CPAP mask daily, and store the CPAP equipment in a bag or enclosed storage when not in use. During observations, the resident’s CPAP and nasal oxygen tubing were found laid on the bed, and the CPAP mask was observed draped over the CPAP machine on the bedside table, with the respiratory equipment not stored in a sanitary container. A CNA stated the equipment should be stored in a bag and pulled shut, while an LPN stated she was unsure how the equipment should be stored and said respiratory staff handled respiratory issues during the day. An administrative nurse stated all respiratory equipment should be placed in a bag when not in use and that all staff could place the equipment in the bags. The facility did not provide storage of respiratory equipment as requested.
Respiratory Equipment Not Properly Labeled or Stored
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for one resident by not ensuring respiratory equipment was properly changed, labeled, and stored. The resident had an admission date of 04/20/2023 and diagnoses including iron deficiency anemia, morbid obesity, diffuse traumatic brain injury with loss of consciousness, and unspecified convulsions. On 06/01/2026, an undated aerosol mask attached to a nebulizer machine was observed on the resident’s nightstand, open to air. The resident had an order for ipratropium-albuterol solution, 1 vial inhaled orally four times a day for wheezing and cough for 5 days, with a start date of 05/28/2026. On 06/02/2026, the same aerosol mask remained on the nightstand, open to air. An LPN confirmed the mask was open to air and not labeled or stored properly, and the DON confirmed the aerosol mask and tubing had not been dated or stored properly.
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