Delayed Response to Resident Respiratory Distress After Dislodged Tracheostomy
Penalty
Summary
The deficiency involves the facility’s failure to timely address a resident’s change in respiratory condition after the resident’s tracheostomy inner cannula became dislodged. The resident had a history of tracheostomy, chronic respiratory failure with hypoxia, laryngeal cancer, malnutrition, and received oxygen therapy, trach care, suctioning, and enteral nutrition. The care plan included maintaining oxygen saturation at or above 92% with humidified oxygen via trach mask and providing suctioning and positioning for easier breathing. The resident was cognitively intact, dependent on staff for several ADLs, and had a full code order, later electing hospice with orders to discontinue labs and not hospitalize. On the morning of the incident, the resident’s trach inner cannula became dislodged around 5:50 A.M., and a CNA observed the resident waving and pointing to the disconnected trach equipment, indicating difficulty breathing. The CNA immediately notified an LPN, who was passing morning medications, that the resident was having trouble breathing and that the trach hose was disconnected. The LPN told the CNA to give him a few minutes to finish medication administration instead of immediately assessing the resident. The CNA remained with the resident for about eight minutes, then left to notify another CNA that the LPN had not yet come, and then resumed care of other assigned residents. During this period, the resident remained without timely nursing assessment or intervention for the reported respiratory distress. When the LPN eventually entered the room, he observed the resident in respiratory distress and attempted suctioning, at which point the resident pulled out the entire trach tube. The LPN was unable to reinsert the trach tube and left the resident to go to other units to obtain help from additional nurses, leaving the resident alone. Multiple LPNs then returned to the room together, at which time the resident was described as grey and not breathing, with the trach tube lying on his chest. CPR was initiated and EMS was called, but staff accounts and documentation showed inconsistencies and lacked clear times for the onset of distress, initiation of CPR, and EMS contact. The facility’s own investigation and leadership interviews confirmed there was a delay in addressing the resident’s change in condition, that a staff member did not remain with the resident, and that a code was not called through the overhead paging system as expected by facility policy.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.