Failure to Ensure Competent Nursing Staff for Tracheostomy Care and Emergency Management
Summary
The deficiency involves the facility’s failure to ensure that licensed nurses had the specific competencies and skills necessary to care for a resident with a tracheostomy, as required by the resident’s assessments and care plan. The resident was an older male with diagnoses including epileptic seizure, shortness of breath, other specified respiratory disorders, and a tracheostomy related to laryngeal injury. His care plan identified him as being at risk for alterations in respiratory status and directed that a disposable Shiley #6 inner cannula be changed every shift, with extra trach tube and obturator kept at bedside and specific steps to follow if the tube was coughed out. The resident’s MDS showed severe cognitive impairment, dependence for personal care, shortness of breath when lying flat, and a need for trach care and suctioning. On two separate dates, the resident’s tracheostomy became dislodged while under the care of facility nursing staff. In one incident, a progress note documented that a nurse found the trach no longer in place; the resident’s oxygen saturation was 94% and he denied shortness of breath, and he was sent to the hospital where the trach was replaced via bronchoscopy. In a later incident, another progress note documented that while a nurse was replacing the trach tie, the resident coughed and the trach came out; the trach was replaced, the resident had difficulty breathing, was given 2L of oxygen, and was again sent to the hospital. The hospital emergency department record for the second event stated that nursing home staff had put the trach back in after it became dislodged and were unsure if it was in the correct position, though it appeared appropriately positioned on evaluation. Interviews with staff revealed gaps in tracheostomy-related competencies and knowledge. One RN reported that the resident’s trach had dislodged twice on her shifts, that another nurse had to replace the trach on one occasion, that she did not feel comfortable replacing the entire trach (only the inner cannula), and that she did not know the trach could be expelled by coughing. She stated her last trach training was likely in 2023. An LVN assigned to the resident stated that if the trach fell out, she would call the nurse practitioner and send the resident to the hospital immediately and that she would not know how to replace it. Another LVN demonstrated awareness of the emergency trach kit in the room and stated she would replace the trach using the correct size, but also reported she had not received trach training or a skills checkoff at this facility since starting work there. Additional interviews showed that key clinical leaders lacked full understanding of trach sizes and the specific size required for this resident. The DON stated she was not the most knowledgeable about trach sizes and could not explain the different sizes of trachs and inner cannulas. During an observation in the resident’s room, the DON and RCS reviewed trach supply boxes labeled with product codes and the RCS initially interpreted inner cannula diameters from package diagrams, then later reported she had spoken with the RT to clarify that the first number in the label indicated size and that the resident used a size 6 Shiley trach. The nurse practitioner stated that the resident’s trach order for a size 6 inner cannula meant a 6 mm inner cannula and that nursing staff should use a 6 mm inner cannula. The RT explained the meaning of the trach product code and that emergency supplies should include the resident’s trach size and a smaller size. Record review showed that competency assessments for two nurses had been marked as “met” for trach care and emergency decannulation procedures, but the prior ADON reported that most nurses, including these two, had not attended prior hands-on trach training and that they did not feel comfortable providing that type of care. The surveyors determined that these findings demonstrated that multiple licensed nurses, as well as the DON and RCS, lacked the necessary competencies and knowledge regarding tracheostomy care, emergency response to accidental decannulation, and trach sizing for this resident. This failure to ensure competent nursing staff for tracheostomy management led to an Immediate Jeopardy determination related to the resident’s care.
Removal Plan
- Resident #1 was assessed by the Respiratory Therapist related to respiratory and tracheostomy status with no concerns noted.
- The Respiratory Therapist validated that physician orders and plan of care for Resident #1's tracheostomy care were being followed.
- The Respiratory Therapist observed the bedside and emergency tracheostomy equipment for Resident #1 and confirmed the presence of size 6, size 5 and size 4 tracheostomies, as well as an Ambu bag for emergency use.
- The Director of Nursing was reeducated by the Respiratory Therapist and received 1:1 education with passed return demonstration on tracheostomy care, emergency response during 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.
- Licensed nurses were reeducated on responsibility for checking and stocking tracheostomy supplies each shift and as needed.
- LVN A was reeducated by the Director of Nursing, Respiratory Therapist and/or designee and received 1:1 education with passed return demonstration on tracheostomy care, emergency response during 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.
- RN A will be reeducated by the Director of Nursing, Respiratory Therapist and/or designee before her next shift and will receive 1:1 education with passed return demonstration on tracheostomy care, emergency response during 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.
- Licensed nurses were reeducated 1:1 by the Director of Nursing, Respiratory Therapist and/or designee with passed return demonstration on tracheostomy care, emergency response during 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.
- Licensed nurses who are out on PTO/FMLA/leave of absence will have the re-education completed and return demonstration prior to the start of their next scheduled shift.
- Newly hired licensed nurses will receive this training and pass a return demonstration during orientation prior to providing care to residents.
- New admissions/readmissions with tracheostomies will be reviewed by the Director of Nursing and/or designee for compliance with physician orders for tracheostomy size and the presence of appropriate tracheostomy sizes, equipment and Ambu bag at bedside.
- The Director of Nursing and/or designee will monitor compliance with physician orders for tracheostomy care and presence of accurate emergency tracheostomy equipment at the bedside by validating through rounding on residents with a tracheostomy.
- The Director of Nursing and/or designee will monitor compliance with licensed nurse competency in tracheostomy care via observations and competency checks.
- The Director of Nursing and/or designee will monitor compliance with daily verification and documentation of presence of emergency supplies at resident bedside (extra tracheostomy in current size, one size down, and Ambu bag) by rounding on residents with tracheostomy.
- An Ad Hoc QAPI meeting was held with the Medical Director, Facility Administrator, Director of Nursing, Regional Clinical Specialist and Regional President of Operations to discuss the immediate jeopardy and review the plan of removal.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to ensure adequate RN or RT coverage for two ventilator-dependent residents whose care plans and orders required frequent ventilator checks, trach care, suctioning, HME and circuit changes, and close monitoring of respiratory status. On at least one night shift, only LPNs were on duty with no RN or RT present, despite these residents’ dependence on mechanical ventilation and tracheostomies. The DON acknowledged there was no RN or RT on that shift, believed prior daytime RN presence met requirements, allowed LPNs to perform ventilator care without certification or documented competency, and was unsure whether such care was within LPN scope of practice. Cited literature from the National Library of Medicine noted that mechanical ventilators are complex, require specific training, and are best managed by RTs, with improper management linked to poor outcomes.
A resident with a PICC line for IV cefepime therapy and multiple comorbidities received IV medication from an LPN who attached IV tubing directly to the open end of the PICC line without a needleless connector, after cleaning only the open hub. The LPN stated that PICC lines do not have valves, despite reporting prior IV therapy training. Facility leadership and HR reported they did not maintain competency or training records for agency staff, and one agency only verified licensure while another provided a self-assessment showing the LPN rated IV skills as limited and requiring supervision, even though the facility’s contract assigned responsibility for orientation, education, and competency of agency staff to the facility.
A staff member was hired and worked in the capacity of a CNA for an extended period without ever obtaining CNA certification or being listed on the Nurse Aide Registry. HR records and interviews showed that the individual completed two Nurse Aide Training classes and repeatedly failed the written competency test, yet was still permitted to perform CNA duties and provide direct care to residents. The personnel file contained only training completion certificates and no verification of an active CNA certification or registry check, affecting care provided to all residents in the facility.
A CNA transferred a resident with cognitive and physical impairments using a mechanical lift without a second staff member present and without having received proper training on the equipment, in violation of facility policy requiring two trained staff for such transfers.
A resident with complex medical needs did not receive prescribed IV vancomycin through a PICC line because no RN was available to administer the medication. The medication was delivered, but scheduled doses were missed due to the absence of qualified staff, despite facility policy requiring timely administration of medications.
Two residents with midline IV catheters for UTI treatment had their catheters removed by an LPN who lacked documented training and was not qualified under state regulations or facility policy to perform this procedure. Staff interviews and record reviews confirmed that the LPN did not have the required competencies, and there was confusion among staff about the scope of LPN practice regarding midline IV removal.
Insufficient Qualified Nursing and Respiratory Staff for Ventilator-Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient qualified RNs or RTs were available to care for residents requiring ventilator support. Resident #1 was admitted with sepsis, pneumonia, and acute and chronic respiratory failure with hypoxia and had physician orders for ventilator checks every four hours and as needed, tracheostomy care every shift and as needed, suctioning via trach as needed, and daily HME changes. Care plans for Resident #1 documented dependence on a ventilator and tracheostomy, with goals to maintain adequate oxygenation and be free from respiratory distress, and interventions including monitoring lung sounds and oxygen levels, providing respiratory treatments and oxygen as ordered, and ensuring ventilator settings were correct. Resident #2 was admitted with anemia, ventilator dependence, and functional quadriplegia, and had care plans indicating alteration in respiratory function related to respiratory failure, tracheostomy, ventilator use, and a history of aspiration pneumonia and mucus plugging. The care plans for Resident #2 included goals to remain free from respiratory distress and maintain oxygen levels at provider-set targets. Interventions required included ventilator checks every four hours, AVAP per physician order, tracheostomy tube changes every 30–45 days by an RT, regular changes of ventilator circuits, HMEs, inner cannulas, trach ties, and nebulizer setups, as well as suctioning, CPT, aerosol treatments, and close monitoring of lung sounds, oxygen levels, and signs of dyspnea. Review of staffing schedules for a specified week showed that on one night shift there were three LPNs on duty and no RTs or RNs present, despite the presence of two ventilator-dependent residents. In an interview, the DON confirmed that there was no RN or RT on that night shift and stated he believed that having an RN in the building earlier in the day met requirements and that LPNs could care for ventilator residents based on education and observation, even though they had no certification or documented return demonstration. The DON also stated he was unsure whether ventilator care was within the LPN scope of practice. Literature from the National Library of Medicine cited in the report emphasized that mechanical ventilators are sophisticated devices requiring specific training, that inappropriate management can result in poor patient outcomes, and that RTs are best suited to manage and adjust ventilators, underscoring the need for appropriately trained personnel.
Failure to Ensure Competent IV Therapy Administration by Agency LPN
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an IV medication was administered by a competent licensed nurse and to verify and document IV therapy competencies for an agency LPN. A resident was admitted with a postoperative wound infection, a PICC line placed in the right upper arm for long-term IV antibiotic therapy, and multiple comorbidities including diabetes, liver disease, hypertension, anemia, depression, and a history of stroke. The resident had an order for IV cefepime 2 g in 100 ml normal saline to be given three times daily via the PICC line. On observation, the PICC line had a flesh-colored bandage wrapped around the base, obscuring the insertion site, and the external catheter had a purple open-ended hub labeled “5 ml” with no needleless connector/valve attached. During administration of IV cefepime, the LPN cleaned the open end of the external PICC with an alcohol swab, flushed with normal saline, and then attached the IV tubing directly to the open end of the PICC line without a needleless connector device. When questioned, the LPN stated that PICC lines she worked with never had valves and that this was how PICC lines are, despite reporting that she had IV therapy training and certification. Licensure review showed the LPN had been licensed less than a year and, per the Ohio Board of Nursing, IV certification is no longer listed on LPN licenses for those licensed after a certain date, making IV training and competency verification the employer’s responsibility. The Human Resource Director reported she did not maintain personnel files, licensure checks, or competency records for agency staff, and the interim DON reported having no education or competency documentation for the LPN other than IV training provided after the issue was identified, stating that the agency would have competency records. The Administrator reported that one staffing agency only verified licensure and did not check competencies, and that another agency provided only a self-assessment skills checklist on which the LPN rated her IV therapy skills as limited and requiring supervision. The facility’s contract with that agency specified that the facility was responsible for orientation, education, training, and competency of agency staff.
Uncertified Staff Member Allowed to Perform CNA Duties
Penalty
Summary
The facility failed to ensure that a staff member working as a CNA met state and federal requirements before providing direct resident care. Human Resources records and interviews showed that this individual was hired as a CNA and provided care to residents for approximately 17 months without ever obtaining CNA certification or being listed on the Nurse Aide Registry. The HR Director reported that the staff member completed an initial Nurse Aide Training class and repeatedly attempted the CNA test but failed the written portion multiple times, then missed a subsequent test and was required to retake the entire training. After completing a second Nurse Aide Training class, the staff member again failed the written test and never achieved certification. Despite this, the facility allowed the individual to continue performing CNA duties and providing care to residents throughout the facility. Review of the personnel file confirmed only certificates of completion for two Nurse Aide Training classes and no documentation of a Nurse Aide Registry check or active certification. This deficiency was identified through personnel record review and staff interviews and was associated with complaint investigations, with the facility census noted as 60 residents at the time of the survey. The report states that this failure had the potential to affect all residents residing in the facility.
Failure to Train Staff on Mechanical Lift Use and Adherence to Transfer Protocols
Penalty
Summary
The facility failed to ensure that staff were properly trained and demonstrated competency in the use of mechanical lifts, as required by facility policy. Observation revealed that a Certified Nursing Assistant (CNA) attempted to transfer a resident with dementia, muscle weakness, and impaired balance from bed to wheelchair by pulling the resident to a standing position multiple times before resorting to a mechanical lift. The CNA then used the mechanical lift to transfer the resident without the assistance of a second staff member, contrary to the facility's policy that mandates at least two staff for such transfers. Interviews with the CNA and the Administrator confirmed that the CNA had not received training on the use of mechanical lifts upon hire and that two staff should be present during mechanical lift transfers. The facility's policy also requires staff to be trained and demonstrate competency with the specific equipment used. The deficiency was identified during a review of residents dependent on mechanical lifts, affecting one resident directly observed and potentially impacting others.
Failure to Provide Qualified Staff for IV Medication Administration via PICC Line
Penalty
Summary
The facility failed to ensure that qualified staff were available to administer intravenous (IV) medication through a Peripherally Inserted Central Catheter (PICC) line for a resident who required this level of care. The resident, who had diagnoses including multiple sclerosis, neuromuscular dysfunction of the bladder, and Crohn's disease, was admitted and later readmitted to the facility. Following a hospital visit for a urinary tract infection, the resident was discharged with a new order for vancomycin IV to be administered every twelve hours via a PICC line. The medication was delivered to the facility, but was not administered as ordered. Documentation and staff interviews revealed that the doses of vancomycin scheduled for administration were missed because there was no Registered Nurse (RN) available to initiate the medication through the PICC line. The Director of Nursing (DON) confirmed that she was the only RN on staff and was not present to administer the medication, and the Assistant Director of Nursing (ADON) was no longer employed at the facility. Facility policy required that medication be administered without unnecessary interruptions and in accordance with prescriber orders, but this was not followed due to the lack of qualified staff.
Unqualified LPNs Removed Midline IV Catheters
Penalty
Summary
The facility failed to ensure that only qualified personnel removed midline intravenous (IV) catheters for two residents who had received IV therapy for urinary tract infections. Both residents were cognitively intact and had midline IV catheters placed at the facility by an outside specialty nursing service. After completion of their IV antibiotic courses, a Licensed Practical Nurse (LPN) removed the midline IV catheters for both residents, despite lacking documented training or qualifications specific to midline or peripherally inserted central catheter (PICC) procedures. Review of the LPN's personnel file showed only basic IV training certification from 2014, with no evidence of midline or PICC-specific training. Facility policy and the Ohio Administrative Code specify that LPNs are not permitted to initiate or discontinue a PICC or any catheter longer than three inches, which includes midline catheters. Interviews with facility staff and the Regional Director of Clinical Services (RDCS) confirmed that the LPN was not qualified to remove the midline IV catheters and that there was confusion among staff regarding the scope of practice for LPNs in this area. The deficiency was identified through record review, staff and resident interviews, and policy review, which collectively demonstrated that the facility did not ensure nurses and nurse aides had the appropriate competencies to care for residents with midline IV catheters. The RDCS acknowledged a lack of IV training for staff and was unaware of the specific state regulations prohibiting LPNs from removing midline catheters. Both residents reported no discomfort or issues following the removal, but the removals were performed by unqualified personnel in violation of state regulations and facility policy.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
