F0695

K

Failure to Ensure Competent Tracheostomy Care and Emergency Preparedness

Wharton, Texas Survey Completed on 02-06-2026

Penalty

Fine: $11,444

Summary

The deficiency involves the facility’s failure to provide safe and appropriate respiratory care, including tracheostomy care and tracheal suctioning, to a resident with a tracheostomy, in accordance with professional standards, the care plan, and physician orders. The resident had a history of tracheostomy related to laryngeal injury, shortness of breath, other specified respiratory disorders, and severe cognitive impairment, and required trach care and suctioning. The care plan and orders specified use of a Shiley size 6 trach inner cannula, routine trach care every shift, and maintenance of an extra trach tube and obturator at the bedside for tube-out procedures.

On two separate occasions, the resident’s trach became dislodged. On the first occasion, an RN entered the room and found the trach out; the resident did not appear in respiratory distress, and the RN notified the nurse practitioner, who ordered transfer to the emergency room. Hospital records documented that the resident was sent for trach replacement due to a dislodged trach, and the trach was replaced via bronchoscopy. On the second occasion, during trach care while the RN was changing the gauze and trach ties, the resident coughed and the trach “blew out.” The RN reported she did not know this could happen and did not feel comfortable replacing the entire trach, only the inner cannula. Another nurse replaced the trach, the resident had difficulty breathing, was placed on oxygen, and was again sent to the hospital, where the ED noted the trach had been reinserted by facility staff who were unsure of correct placement.

Surveyor interviews and observations showed that staff caring for the resident were not consistently aware of the location of emergency trach equipment or how to use it in the event of accidental extubation. One LVN stated that if the trach fell out, she would call for help, call the nurse practitioner, and send the resident to the hospital because that was how he breathed, and she would not know how to replace it; when she showed the surveyor the resident’s supplies, there was no trach kit with insertion tool at the bedside. Another RN who assisted during the second dislodgement reported inserting a smaller-sized trach because that was what was available at the bedside, and later replacing it with the correct size after being instructed by the nurse practitioner, but she could not recall the sizes used. Additional interviews with central supply, the DON, and other clinical staff revealed confusion and lack of clear understanding regarding trach sizing, the specific size ordered for the resident, and which emergency trach sizes were present at the bedside. The facility also lacked a written policy on respiratory or trach care and relied on an external nursing manual instead of a facility-specific protocol. These findings led surveyors to identify an Immediate Jeopardy situation related to failure to ensure staff competency, equipment availability, and correct trach sizing for this resident.

The Immediate Jeopardy determination was based on three core failures: staff caring for the resident were not consistently aware of the location of emergency trach equipment or how to use it in case of accidental extubation; the resident did not have a same-size trach immediately available at the bedside on at least one occasion when the trach became dislodged; and staff were not consistently knowledgeable about trach sizes or the specific size required by the resident per physician order. These failures occurred despite the resident’s documented need for trach care and suctioning and the care plan requirement to keep an extra trach tube and obturator at the bedside for tube-out procedures.

Removal Plan

• Assess Resident #1 by the Respiratory Therapist related to respiratory and tracheostomy status with no concerns noted.
• Validate that physician orders and plan of care for Resident #1's tracheostomy care are being followed.
• Observe the bedside and emergency tracheostomy equipment for Resident #1 and confirm the presence of size 6, size 5 and size 4 tracheostomies, as well as an Ambu bag for emergency use.
• Reeducate the Director of Nursing by the Respiratory Therapist and provide 1:1 education with return demonstration on tracheostomy care (including supplies), emergency response to accidental extubation (including reinsertion, size identification, equipment location/use), and daily shift observation/documentation for compliance with physician orders and presence of emergency equipment at bedside.
• Reeducate Licensed Nurses on responsibility for checking and stocking tracheostomy supplies each shift and as needed.
• Reeducate LVN A by the Director of Nursing, Respiratory Therapist and/or designee and provide 1:1 education with return demonstration on tracheostomy care, emergency response to accidental extubation (including reinsertion, size identification, equipment location/use), and daily shift observation/documentation for compliance with physician orders and presence of emergency equipment at bedside.
• Reeducate RN A by the Director of Nursing, Respiratory Therapist and/or designee before her next shift and provide 1:1 education with return demonstration on tracheostomy care, emergency response to accidental extubation (including reinsertion, size identification, equipment location/use), and daily shift observation/documentation for compliance with physician orders and presence of emergency equipment at bedside.
• Reeducate 100% of Licensed Nurses 1:1 by the Director of Nursing, Respiratory Therapist and/or designee with return demonstration on tracheostomy care, emergency response to accidental extubation (including reinsertion, size identification, equipment location/use), and daily shift observation/documentation for compliance with physician orders and presence of emergency equipment at bedside.
• Complete re-education with return demonstration for Licensed Nurses who are out on PTO/FMLA/Leave of Absence prior to the start of their next scheduled shift.
• Provide this training to newly hired licensed nurses and require passing a return demonstration during orientation prior to providing care to residents.
• Review new admissions/readmissions with tracheostomies by the Director of Nursing and/or designee for compliance with physician orders for tracheostomy size and for the presence of appropriate tracheostomy sizes, equipment and Ambu bag at bedside.