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:
Insulin Pen Priming Competency Not Verified: An LPN administered Humalog insulin to a resident without priming the Kwik Pen first and stated she was unaware that priming was required. The facility could not produce the nurse's skills check sheet, and the competency form reviewed did not include priming an insulin pen, despite the insulin instructions stating the pen must be primed before each injection.
A facility failed to ensure a QMA had a current license while distributing meds to residents. Record review showed the QMA was scheduled and worked on multiple days across 3 resident units, but the licensure binder and Indiana License Registry showed the QMA's license had expired. The ED stated staff should not distribute meds with an expired QMA license and that the facility had no written policy requiring QMAs to work with a current license.
Missing Mandatory Orientation and Training for Agency CNA: The facility assigned an agency CNA to provide resident care without documentation showing completion of required orientation and in-service training. The CNA stated they did not receive orientation, a training packet, or training on abuse/neglect, dementia care, behavioral health, trauma-informed care, or managing difficult behaviors before working on resident units. The ADON/Staff Educator and DON stated the required training should have been completed and documented in the employee file, but the records could not be located.
CNA Competency Review Completed After Annual Evaluation: The facility failed to ensure that a CNA received a comprehensive clinical competency skills review before the CNA's annual performance evaluation. Record review showed the CNA's annual performance review was completed before the competency review, and the DSD stated she was unaware of the requirement that the skills competency evaluation be completed prior to the annual evaluation.
Incompetent PEG Tube Medication Administration: An LPN was observed administering crushed medication via a resident’s PEG tube but poured the diluted medication directly into the tube without a syringe, causing it to spill. The LPN then did not know how to connect the syringe to the PEG tube and had to call for help, while the DON provided instruction. The resident had diagnoses including an unstageable sacral pressure ulcer, pain, and aphasia following cerebral infarction, and the DON stated the resident did not receive the full dose of medication.
A resident with urinary retention and BPH required a coude catheter, but when the catheter became obstructed, an LPN told the resident to wait until day shift for a change and did not notify the RN supervisor or seek help. Facility records showed no competency training, return demonstration, or skills validation for Foley or coude catheter care, and multiple nurses said they had not received facility-specific education or competency checks for coude catheter management.
Insulin Pen Priming Competency Not Verified
Penalty
Summary
The facility failed to ensure staff possessed the skills and competencies required when a Licensed Nurse administered Humalog insulin to R19 without priming the Kwik Pen first. On 06/02/2026 at 10:13 AM, R19 walked in the hall with a walker, then went to her room with the nurse to receive insulin. The nurse clicked up seven units in the pen and administered the insulin in R19's left arm without priming the pen, and then verified that she had not primed it and stated she was unaware she was supposed to. When the facility was asked for the nurse's skills check sheet, it could not provide it. Review of a blank medication pass competency check sheet showed no competency assessment for priming an insulin Kwik Pen. The insulin pen instructions in the pamphlet directed staff to prime the pen before each injection, and Administrative Nurse D stated she expected staff to prime the insulin pen with two units before administration. She also stated that nurses were required to complete an insulin competency check-off upon hire, and later verified that the nursing skills check lacked a competency item for priming an insulin Kwik Pen.
Expired QMA License During Medication Distribution
Penalty
Summary
The facility failed to ensure that a Qualified Medical Assistant had a current license while distributing medications to residents. A record review showed that QMA 3 was scheduled to distribute medications and had worked as a QMA on multiple days across three resident units from April through the review period. The facility's Employee Certification and Licensure binder showed that QMA 3's license had expired, and the Indiana License Registry website also indicated the license was expired. In interviews, the Executive Director stated that staff should not distribute medications with an expired QMA license and that the facility did not have a written policy requiring QMAs to work with a current license.
Missing Mandatory Orientation and Training for Agency CNA
Penalty
Summary
Certified Nurse Aide #1 was assigned resident care duties on 05/11/2026 as agency staff, but the facility could not provide documentation showing completion of required orientation and mandatory training before the aide worked independently. The missing documentation included, but was not limited to, Abuse/Neglect/Exploitation Prohibition, Behavioral Care Services/Cognitive Impairment/Dementia Training, Trauma Informed Care, Communication Training, and other required orientation and in-service training elements. During the survey, the Assistant Director of Nursing/Staff Educator stated agency staff are required to complete the same mandatory orientation and in-service training as facility staff and that training modules, sign-off documentation, and post-tests are maintained in employee files. However, the facility was unable to locate records verifying that Certified Nurse Aide #1 completed the required training. Certified Nurse Aide #1 stated they did not receive orientation, a training packet, or any of the listed training topics before being assigned to provide resident care on Units 2 and 3. The Administrator also stated that all staff are required to complete mandatory orientation and in-service training prior to working independently and that documentation should have been maintained in the employee file.
CNA Competency Review Completed After Annual Evaluation
Penalty
Summary
The facility failed to implement its policy regarding nursing staff competency by not ensuring that CNA 3 received a comprehensive clinical competency skills review before the CNA's annual performance evaluation. During a concurrent interview and record review on 5/29/2026 at 12:18 p.m., the Director of Staff Development reviewed CNA 3's personnel file, the C.N.A. Comprehensive Clinical Competency Review- Skills Checklist form, and the Annual Performance Review form. The review showed that CNA 3's clinical competency review was completed on 1/22/2026, while the annual performance evaluation was completed earlier, on 12/24/2025. During a concurrent interview and record review on 5/29/2026 at 12:26 p.m., the Director of Staff Development reviewed the facility's policy titled Nursing Staffing Competency and stated she was unaware of the facility's requirement that the annual skills competency evaluation be completed prior to a CNA's annual performance evaluation. The policy stated that the facility will identify annual skills competencies needed for each role and establish a schedule or process to facilitate completion of skills and competency evaluations, and that successfully completed orientation and skills check are required prior to the employee's annual evaluation.
Incompetent PEG Tube Medication Administration
Penalty
Summary
The facility failed to ensure licensed nurses had the necessary competency skills to administer medication via PEG tube for one resident. During an observed medication pass, an LPN prepared crushed medication for the resident’s PEG tube, donned a gown and gloves, stopped the tube feeding, and checked placement and residual. The LPN then poured water and the crushed medication into a 30 ml cup and attempted to pour the diluted medication directly into the PEG tube without using a syringe, causing the medication to spill out over and around the tube. The LPN then obtained another cup with diluted medication and a syringe but did not know how to connect the syringe to the PEG tube, hesitated, activated the call light, and stated they would call for assistance. The DON later entered the room and provided instructional assistance to the LPN on administering medication through the PEG tube. The resident had diagnoses including an unstageable sacral pressure ulcer, pain, and aphasia following cerebral infarction. A physician order directed flushing the PEG tube with 30 ml of water before and after medications and 15 ml between each medication. The LPN stated they were unsure how much medication the resident received when the diluted medication spilled during administration. The DON stated the LPN did not correctly administer the medication via the PEG tube, that the medication was spilled and the resident did not receive the full dose, and that the LPN should have notified the physician. The DON also stated the facility used skills competency checklists upon hire and yearly during a skills fair, but the LPN did not have a skills competency checklist completed upon hire and was past the 90-day timeframe for completion.
Lack of competency validation for coude catheter care
Penalty
Summary
The facility failed to ensure licensed nursing staff possessed and demonstrated the competencies needed to safely assess, manage, and provide care for residents requiring a coude catheter. Resident 9 was admitted with urinary retention and benign prostatic hyperplasia with lower urinary tract symptoms, and a care plan dated March 30, 2026, identified the need for a coude catheter. On May 7, 2026, nurse documentation and interview with the DON showed the resident’s coude catheter became obstructed during the night shift, and the LPN on duty told the resident he would need to wait until day shift staff arrived for the catheter to be changed. The DON stated the LPN reported she was not comfortable changing the coude catheter because of a lack of familiarity and experience with that type of catheter, and she did not notify the RN supervisor or seek assistance to ensure timely catheter intervention. Review of facility documentation titled Skilled Nursing Competency Training showed competencies listed for licensed practical nurses, including nephrostomy tubes and suprapubic catheters, but the facility did not include competency training, return demonstration, or skills validation for Foley catheter insertion, Foley catheter management, or coude catheter care and replacement. During interviews, four licensed nurses stated they had general catheter education in nursing school and prior experience with coude catheters at previous employers, but all reported the facility had not provided facility-specific education, training, competency evaluation, or skills validation related to coude catheter care, evaluation, insertion, replacement, or management. The DON was unable to provide documented evidence that licensed nursing staff had completed education, training, competency evaluations, or demonstrated proficiency for Foley catheter care or specialized coude catheter management.
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