Failure to Ensure Competent Tracheostomy Care and Emergency Preparedness
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.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Two residents receiving O2 had flow rates set above their physician orders, and one resident’s tubing remained dated beyond the weekly change interval. Staff, including an RN and the DON, confirmed the mismatched flow rates and noted that tubing should be changed weekly by the RT. The facility policy required O2 to be administered per physician order and tubing/cannula to be changed weekly.
Oxygen Concentrator Left in Room After Order Discontinued: A resident with morbid obesity with alveolar hypoventilation and diabetes was observed with an oxygen concentrator at bedside even though there was no current oxygen order. The resident stated he used oxygen only when needed, and the CNO confirmed the oxygen had been discontinued earlier and the concentrator should not have remained in the room.
Missing Order for CPAP Use and Maintenance: A resident with sleep apnea and stroke had a CPAP in the room, but there was no physician order or care plan documentation for its use or maintenance. Staff knew the resident had the CPAP, yet CNAs and an RN reported they did not routinely clean the mask or tubing, and the LPN Resident Care Manager confirmed no order existed for the CPAP or its care.
A resident with a continuous O2 order was found without oxygen in place, and an LPN later said the order had been misread. Two other residents with COPD had respiratory equipment that was dirty or outdated, including a gray concentrator filter, tubing and water bottles dated weeks earlier, and tubing lying on the floor with visible dust. Staff gave inconsistent accounts of who was responsible for changing or cleaning the equipment, and the DON acknowledged the dirty equipment and old mask placed residents at risk for respiratory infection or pneumonia.
A resident with acute respiratory failure with hypoxia and severe cognitive impairment was ordered oxygen via NC at 2 to 5 LPM to keep O2 saturation at or above 95%. During observation, the resident was lying in bed with the NC on the side of the face instead of in the nose while the concentrator was set at 2.5 LPM. RN and DON stated the NC should be in the nose to deliver oxygen as ordered.
A resident with COPD and chronic respiratory failure did not receive oxygen at the ordered flow rate. Staff found the oxygen concentrator set below the ordered amount on multiple observations, and the resident stated the oxygen was supposed to be set higher. The DON, LVNs, and ADON acknowledged the setting was incorrect and that the ordered flow should have been followed.
Incorrect Oxygen Flow Rates and Delayed Tubing Changes
Penalty
Summary
The facility failed to provide respiratory care consistent with physician orders for two residents receiving oxygen therapy. Resident #5 had an order dated 1/7/2025 for oxygen at 2 liters via nasal cannula continuously for infiltrate of the left lung, but during observations on 7/7/2026, 7/8/2026, and 7/9/2026 the resident’s oxygen was running at 3 liters per minute. On 7/7/2026 and 7/8/2026, the oxygen tubing in Resident #5’s room was dated 6/26, and on 7/9/2026 Staff F, RN confirmed the tubing date and the 3-liter flow rate. Staff F stated the tubing should have been changed the prior week and that the resident was running at 3 liters despite an order for 2 liters. Resident #6 had a physician order dated 3/18/2026 for oxygen at 3 liters via nasal cannula continuously for chronic respiratory failure with hypoxia, but during observations on 7/7/2026 at 10:10 AM and 12:12 PM, and again on 7/8/2026 at 8:02 AM, the resident’s oxygen was being administered at 4 liters per minute. On 7/9/2026 Staff F, RN entered the room and confirmed the oxygen was at 4 liters, stating it should not be at that rate because the order was for 3 liters. The DON stated nursing staff should check oxygen flow rate every shift and as needed, and that tubing should be changed weekly by the respiratory therapist. The facility policy also stated oxygen tubing and mask/cannula are to be changed weekly and as needed if soiled or contaminated.
Oxygen Concentrator Left in Room After Order Discontinued
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not maintained when the facility failed to remove an oxygen concentrator from Resident #12's room after the physician discontinued the oxygen order. Resident #12 was admitted and later readmitted to the facility with diagnoses including morbid obesity with alveolar hypoventilation and diabetes. On 7/7/26, the resident was observed sitting in his power chair with an oxygen concentrator at his bedside. When asked about oxygen use, the resident stated he only used oxygen when he needed it. Review of the resident's physician orders showed no current oxygen order, and the CNO stated on 7/8/26 that the oxygen concentrator should not have been in the room because oxygen had been discontinued on 6/17/26.
Missing Order for CPAP Use and Maintenance
Penalty
Summary
The facility failed to obtain physician orders for the use and maintenance of a CPAP for Resident 76, who was admitted in 6/2026 with diagnoses including sleep apnea and stroke. There was no documentation in the admission MDS or care plan showing that the resident used a CPAP. Observations from 7/6/26 through 7/10/26 showed the CPAP in the resident’s room on the nightstand. The resident stated that a friend brought the CPAP to the facility a day after admission, but staff did not clean the mask or tubing daily and the mask did not fit well. Staff interviews showed the CNA staff were aware of the CPAP but did not clean the mask or hose, one CNA reported washing the mask one time, and an RN stated she filled the chamber with water a few times but did not clean the mask or tubing. The LPN Resident Care Manager confirmed the resident did not have an order for the CPAP or for cleaning and caring for the equipment.
Respiratory Equipment Not Maintained or Applied as Ordered
Penalty
Summary
Resident #12 had an order for oxygen at 2 liters per minute via nasal cannula continuously, with titration up to 4 liters to keep oxygen saturations above 90% every shift. The resident’s care plan also directed staff to apply oxygen at 2 liters via nasal cannula. During an observation, the resident was up in a chair with no oxygen in place. The resident stated she had been wearing oxygen but was not sure when or why staff stopped applying it. The nurse later stated she had misread the order as oxygen could be applied only if saturations fell below 90%, and she acknowledged the resident did not wear oxygen despite the active continuous order. Resident #27 had diagnoses including dementia, COPD, anxiety, and shortness of breath, and her MDS indicated she required oxygen therapy. Her care plan directed staff to change oxygen tubing as needed and nebulizer tubing every week. During multiple observations, the resident’s oxygen concentrator filter was gray and dirty, and the tubing and empty water bottle were dated 5/24/26. The resident stated staff usually changed the equipment, but it had not been changed that she could recall. Later, the tubing and water bottle remained dated 5/24/26, and the concentrator filter was still dirty. Staff interviews reflected uncertainty about who was responsible for changing the equipment, and the ADON stated the tubing and water bottle should have been changed by 07/02/26, while the DON stated the dirty filter and old nebulizer mask placed the resident at risk for respiratory infection or pneumonia. Resident #9 had COPD and an order for oxygen at 2 to 4 liters per nasal cannula to maintain PO2 greater than 90%. The resident’s oxygen tubing was observed lying on the floor and had a piece of tape dated 06/22/26, with brown dust visible in the wheel-mark pattern on the tubing. The resident was unable to state when the tubing was last changed or how often it was changed. Staff interviews showed differing practices about changing oxygen tubing, with some stating it should be changed weekly or when dirty, while the DON stated she had been advised not to date the tubing and to change it when visibly soiled. The facility policy stated cannula or mask needed to be changed if it malfunctions or becomes visibly contaminated.
Oxygen Not Properly Delivered via Nasal Cannula
Penalty
Summary
The facility failed to ensure oxygen was administered in accordance with the physician’s order and facility policy for one sampled resident. Resident 44 was admitted with diagnoses including acute respiratory failure with hypoxia and encephalopathy. The MDS dated 5/28/2026 indicated the resident had severe cognitive impairment, was on oxygen therapy, and was dependent for eating, oral care, toileting, personal hygiene, showering, dressing, and footwear. A physician’s order dated 6/4/2026 directed oxygen via nasal cannula at 2 to 5 LPM to maintain oxygen saturation at or above 95% every shift, and the care plan was revised to reflect humidified oxygen via nasal cannula at 2 to 5 LPM to maintain oxygen saturation at or above 95% every shift. During a concurrent observation on 6/29/2026 at 10:33 AM, Resident 44 was observed lying in bed with the nasal cannula on the left side of the face while the oxygen concentrator was set at 2.5 LPM. During interviews, RN 3 stated the nasal cannula should be placed correctly in the resident’s nose for the resident to receive oxygen, and the DON stated the nasal cannula should always be in the resident’s nose to help maintain oxygen saturation at 95% and above. The facility policy titled Oxygen Administration stated oxygen is administered to residents who need it, consistent with professional standards of practice and comprehensive person-centered care plans, and under physician orders.
Incorrect Oxygen Flow Settings
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for a resident with COPD, chronic respiratory failure, and functional quadriplegia. The resident’s care plan directed that oxygen be administered at 2 L/min via nasal cannula continuously to maintain SPO2 above 90%, and the physician order summary reflected oxygen at 2 L/min via nasal cannula continuously. However, during observation and interview on 06/30/2026, the resident’s oxygen concentration machine was set at 3 L/min, and the resident stated her oxygen was supposed to be set at 4 L/min. The LVN stated the resident was supposed to be on 4 L/min and adjusted the oxygen to 3.5 L/min, and the DON later stated the resident was to be getting 4 L/min and adjusted the setting to 4 L/min. A subsequent physician order dated 07/01/2026 directed oxygen at 4 L/min via nasal cannula to maintain SPO2 above 90%. During observation on 07/02/2026, the resident’s oxygen was again found set at 3.5 L/min. An LVN checking the setting stated it was at 3.5 L/min and that if physician orders were not followed, the resident could become short of breath and the orders would not be followed. The ADON stated the oxygen machine should be set with the ball meter at eye level, that if the order said 4 L/min it should be set on 4 L/min, and that 3.5 L/min was not good enough. The facility’s oxygen administration policy required verifying a physician order and adjusting the oxygen delivery device so the proper flow of oxygen was being administered.
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