F0695

D

Failure to Maintain Ordered Inner Cannula for Tracheostomy Care

Palos Hills, Illinois Survey Completed on 02-04-2026

Penalty

No penalty information released

Summary

The facility failed to provide an ordered inner cannula for the tracheostomy of one resident during tracheostomy care. The resident is an older adult with diagnoses including cardiac arrest with anoxic brain injury, chronic respiratory failure with hypoxia, tracheostomy and gastrostomy tube, and heart failure. The resident’s MDS showed severely impaired cognitive skills for daily decision making and total dependence on staff for care, requiring assistance of two or more helpers. A physician’s order dated 1/16/2026 directed that the inner cannula be changed twice daily on every day and night shift, and specified a Shiley size 8 FLEX tracheostomy tube. On the survey date at 9:40 AM, the surveyor observed the tracheostomy without an inner cannula in place.

When asked to assess the tracheostomy, a respiratory therapist removed the tracheostomy mask, confirmed there was no inner cannula present, and stated the resident was supposed to have one. The therapist reported having rounded on the resident earlier that morning to provide a breathing treatment but could not explain why the inner cannula was missing. A second respiratory therapist later assessed the tracheostomy, also confirmed the absence of the inner cannula, and stated the resident should have one in place, describing that the inner cannula is changed twice a day and is a safety feature that allows quick removal of mucus plugs or obstructions. The Respiratory Therapist Director stated that staff are expected to change the inner cannula during tracheostomy care every shift or as needed and to ensure it is in place during initial rounds. The facility’s tracheostomy care policy, revised 10/2024, includes use and replacement of an inner cannula as part of routine tracheostomy care, but this was not followed for this resident at the time of observation.