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:
Missing Oxygen Order and Improper Nebulizer Storage: A resident receiving oxygen for sleep apnea had no physician order specifying the oxygen delivery rate, even though staff were setting the rate. In a separate observation, a resident’s nebulizer mask was left unbagged on the nightstand while not in use. An LPN and the DON both stated respiratory equipment should be stored in a bag when not in use, and the facility policy required bagged storage between uses.
Respiratory care was not provided in accordance with standards for several residents receiving oxygen and nebulizer treatments. Staff observed outdated oxygen tubing and humidification equipment, a nebulizer mouthpiece left out with tubing touching the floor, and oxygen supplies not stored properly. One resident’s oxygen was running at a higher flow than ordered, and staff confirmed the tubing and humidification items should be changed weekly and documented.
Improper Storage and Dating of Oxygen and CPAP Equipment: Two residents had oxygen equipment and CPAP items observed out of proper storage, including nasal cannula tubing on the floor, undated or empty humidifiers, and a CPAP mask on the floor. One resident had OSA with an order for oxygen at bedtime and as needed, and the other had COPD with orders for nightly CPAP and continuous oxygen. Staff stated the tubing, humidifier, and CPAP mask should be stored and dated per facility practice, and the facility policy required weekly changes and dating of oxygen equipment.
A resident receiving continuous O2 via nasal cannula had the cannula found on the floor while the concentrator was running. A CNA placed the cannula back on the resident’s face before an LVN identified it as contaminated and replaced the cannula and tubing. The resident had diagnoses including hypertensive heart disease and atherosclerotic heart disease, and the care plan called for O2 at 2 L/min to maintain O2 sats above 92%.
A resident with COPD, a respiratory infection, continuous O2, and CPAP therapy had CPAP and nasal cannula tubing observed lying on the bed and the CPAP mask draped over the machine instead of being stored in a sanitary container. Staff interviews showed inconsistent understanding of how to store the respiratory equipment, and the facility did not provide the requested storage of the equipment when not in use.
Respiratory equipment was not properly changed, labeled, or stored for a resident receiving nebulizer treatment. An undated aerosol mask attached to a nebulizer was observed on the resident’s nightstand, open to air, and remained there on a later observation. An LPN confirmed the mask was open to air and not stored properly, and the DON confirmed the mask and tubing had not been dated or stored properly.
Missing Oxygen Order and Improper Nebulizer Storage
Penalty
Summary
The facility failed to ensure that Resident #11’s oxygen delivery rate was specified in the clinical record. Resident #11 was observed semi reclined in bed receiving oxygen from a concentrator via nasal cannula at 2 liters per minute. The resident’s care plan, initiated 1/2/2026, identified risk for complications related to sleep apnea and included oxygen as needed to promote lung expansion and improve air exchange, with positioning at 45 degrees if tolerated. The physician orders included oxygen-related maintenance and respiratory orders for oxygen at night for sleep apnea, but the clinical record did not contain a physician’s order establishing the ordered oxygen delivery rate. An LPN confirmed the record did not show an ordered delivery rate, and the DON agreed the oxygen delivery rate should be included as a physician’s order. The facility also failed to ensure nebulizer equipment was properly stored for Resident #85. During observations, a nebulizer mask was seen lying on top of the nightstand and was not bagged while the resident was sitting in a wheelchair and later while lying in bed with eyes closed. Resident #85 had physician orders for levalbuterol nebulization every 8 hours and ipratropium-albuterol inhalation solution every 6 hours as needed for shortness of breath. An LPN stated the nebulizer mask and oxygen tubing should be stored in a bag when not in use, and the DON stated the nebulizer mask and tubing should be stored in a dated bag when not in use. The facility policy stated oxygen cannula and tubing used PRN should be kept in a plastic bag when not in use, and nebulizer circuits should be stored in a plastic bag marked with the date and resident’s name between uses.
Respiratory equipment was not maintained and stored per standards
Penalty
Summary
The facility failed to follow professional standards of practice for oxygen and nebulizer treatments for four residents receiving respiratory services. During observations, Resident #56 was receiving continuous oxygen at 4 liters per minute by nasal cannula, and the tubing was dated 5/22 even though staff stated the tubing should be changed weekly on Thursdays. The DON confirmed oxygen tubing is changed weekly. Resident #56’s physician order dated 4/2/2026 ordered continuous oxygen at 4 liters nasal cannula. Resident #29 was observed with oxygen via nasal cannula connected to an oxygen concentrator with a humidification/water bottle dated 5/17/26, and the same date was observed again the next day. Her orders included continuous oxygen at 2 liters and weekly change of tubing, mask, and/or nasal cannula, but there was no order for humidification related to her oxygen and no MAR/TAR entry for humidification. Staff stated the humidification bottles should be changed weekly and at the same time as the tubing, and the DON stated there should be an order for humidification and that tubing and humidification bottles should be documented on the TAR. Resident #55’s nebulizer setup was observed with inhalation tubing hanging from the machine, with the distal tip touching the floor, and the mouthpiece sitting on the bedside table instead of in a plastic storage container. Resident #88 was observed with an oxygen concentrator running at 4.5 liters per minute, while the physician order was for 2 liters continuous; the oxygen cannula was wrapped around the bedside rail and not stored in a bag. The unit manager stated oxygen supplies should be stored in a dated plastic bag and the mouthpiece should not be left on the bedside table.
Improper Storage and Dating of Oxygen and CPAP Equipment
Penalty
Summary
The provider failed to ensure infection control practices were followed for oxygen equipment for two residents. One resident had obstructive sleep apnea and an order for oxygen at 3 L by nasal cannula at bedtime and as needed; observations showed the nasal cannula tubing on the floor and not dated, and the pre-filled humidifier was not dated. The resident’s June 2026 TAR did not indicate when the nurse was to change the oxygen tubing. Another resident had COPD and orders for nightly CPAP use and continuous oxygen at 2 L. Observations showed the oxygen concentrator in the room, the nasal cannula tubing dated but later found on the floor, the pre-filled humidifier empty and not dated, and the CPAP mask on the floor between the bed and nightstand. Staff interviews stated the oxygen tubing should be stored in a bag or in the bedside table drawer when not in use, the CPAP mask should be stored on the CPAP machine, and the tubing and humidifier should be dated when changed. The facility policies stated oxygen tubing and nasal cannula/mask were to be changed weekly, the tubing should be changed when found lying on the floor, and the humidifier bottle should be replaced weekly and as needed with date and initials.
Contaminated oxygen tubing was placed back on a resident
Penalty
Summary
Resident #7, a female admitted on 05/14/2026 with diagnoses including hypertensive heart disease and atherosclerotic heart disease, was ordered to receive oxygen at 2 L/min via nasal cannula continuously every shift. Her MDS indicated that she was rarely/never understood and received oxygen therapy, and her care plan addressed impaired gas exchange related to respiratory failure with oxygen at 2 L/min via nasal cannula to maintain O2 saturations above 92%. During observation on 06/01/2026, Resident #7 was in bed with the head of bed elevated about 30 degrees. The oxygen concentrator was running at 2 L/min, but the tubing was above her head and the nasal cannula was lying on the floor. CNA C picked up the cannula from the floor and placed it back on the resident’s face. LVN A then entered the room and stated the cannula was contaminated and immediately changed it out. CNA C stated she had put the cannula back on because she did not think it had touched the floor, but also acknowledged that it could be contaminated and cause infection if it touched the floor. LVN A stated the cannula and tubing were changed because they had touched the floor and were contaminated. The DON stated the expectation was that tubing or a nasal cannula on the floor are to be changed out to prevent infection.
Respiratory Equipment Not Stored Sanitarily
Penalty
Summary
The facility failed to provide adequate respiratory care and services for a resident with COPD, diabetes mellitus, major depressive disorder, and neuromuscular dysfunction of the bladder who also had a respiratory infection and was receiving continuous oxygen and CPAP therapy. The resident’s MDS documented intact cognition, lower-body extremity impairment, and dependence on staff for toileting, bathing, and dressing, with setup or cleanup assistance needed for eating and oral hygiene. The care plan and physician orders directed staff to assist with CPAP application every bedtime, ensure oxygen was connected at 3 L/min, clean the CPAP mask daily, and store the CPAP equipment in a bag or enclosed storage when not in use. During observations, the resident’s CPAP and nasal oxygen tubing were found laid on the bed, and the CPAP mask was observed draped over the CPAP machine on the bedside table, with the respiratory equipment not stored in a sanitary container. A CNA stated the equipment should be stored in a bag and pulled shut, while an LPN stated she was unsure how the equipment should be stored and said respiratory staff handled respiratory issues during the day. An administrative nurse stated all respiratory equipment should be placed in a bag when not in use and that all staff could place the equipment in the bags. The facility did not provide storage of respiratory equipment as requested.
Respiratory Equipment Not Properly Labeled or Stored
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards for one resident by not ensuring respiratory equipment was properly changed, labeled, and stored. The resident had an admission date of 04/20/2023 and diagnoses including iron deficiency anemia, morbid obesity, diffuse traumatic brain injury with loss of consciousness, and unspecified convulsions. On 06/01/2026, an undated aerosol mask attached to a nebulizer machine was observed on the resident’s nightstand, open to air. The resident had an order for ipratropium-albuterol solution, 1 vial inhaled orally four times a day for wheezing and cough for 5 days, with a start date of 05/28/2026. On 06/02/2026, the same aerosol mask remained on the nightstand, open to air. An LPN confirmed the mask was open to air and not labeled or stored properly, and the DON confirmed the aerosol mask and tubing had not been dated or stored properly.
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