F0726

K

Failure to Ensure Competent Nursing Staff for Tracheostomy Care and Emergency Management

Wharton, Texas Survey Completed on 02-06-2026

Penalty

Fine: $11,444

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.