Failure to Follow Tracheostomy Orders and Maintain Emergency Airway Equipment
Penalty
Summary
The facility failed to provide tracheostomy care consistent with physician orders and professional standards for two residents with respiratory failure. One resident, admitted with acute respiratory failure and with a physician’s order dated 12/7/23 to have the tracheostomy inner cannula changed daily by respiratory therapy, did not have the inner cannula changed for a total of five days, including three consecutive days. Progress notes from 2/13/26 through 2/22/26 documented that the inner cannula was cleaned, rather than changed, on multiple dates (2/13/26, 2/16/26, 2/20/26, 2/21/26, and 2/22/26). The respiratory therapist reported cleaning and reusing the inner cannula for a couple of weeks because replacement inner cannulas were not available, and acknowledged that the inner cannula should have been changed daily per the physician’s order. The RN supervisor also stated it was important to change the inner cannula daily so it would not be clogged and that reusing it multiple times could have been a risk for infection. A second resident, admitted with chronic respiratory failure and with a tracheostomy order specifying a Shiley Covidien size 4 tube, did not have all necessary emergency tracheostomy equipment at the bedside. During observation and interview with the respiratory therapist, the resident was noted to be without a spare inner cannula readily available at bedside, despite the therapist stating that a spare inner cannula was part of the necessary emergency tracheostomy equipment that should be present. The RN supervisor stated that emergency tracheostomy equipment, including the inner cannula, was important to have at bedside to prevent the tracheostomy hole from closing. The DON also stated that emergency equipment, including inner cannulas, should have been at residents’ bedsides. The resident’s respiratory care plan documented the presence of a tracheostomy with risk for congestion and SOB, with a goal to maintain a clear, open airway and an approach of keeping all necessary emergency supplies readily available at all times, which was not followed.
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.