Failure to Maintain Required Spare Tracheostomy Tube at Bedside
Penalty
Summary
Facility staff failed to provide safe and appropriate respiratory care by not maintaining a required spare tracheostomy tube at the bedside for one resident with a tracheostomy. The facility’s policy titled “Unplanned Decannulation: Risk Assessment, Precautions and Interventions” dated 12/09/25 stated that a replacement airway must be kept at the bedside for all airway patients. The resident was admitted with multiple diagnoses including acute and chronic respiratory failure with hypoxia, chronic kidney disease, and hyperkalemia, and had a care plan for risk of respiratory complications related to COPD and respiratory failure. The resident’s MDS showed intact cognition (BIMS score 14) and documented that the resident received oxygen therapy, suctioning, and trach care. A physician’s order directed use of a Shiley trach, size 6.5 cuffless, with specified FiO2 and oxygen saturation parameters. During an observation, the resident was seen in her room in a wheelchair with a tracheostomy and speaking valve in place, and no spare trach tube was found anywhere in the room. The assigned LPN searched behind the bed, on the bed, and in the bedside drawers and confirmed there was no spare trach, stating she did not know the resident did not have one and suggesting it might be on the respiratory cart. In a subsequent interview, the Director of Respiratory Therapy stated that respiratory therapy is responsible for setting up and placing spare trachs and other emergency equipment, such as an Ambu bag, at the bedside for all airway patients except laryngectomy patients, and confirmed that all airway patients must have a spare trach at the bedside in case of accidental dislodgement. When instructed to verify the presence of a spare trach, the assigned respiratory therapist went to the resident’s room, searched, and reported there was no spare trach for the resident, stating he did not know why and that he had just arrived.
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