F0695

J

Failure to Provide Life-Sustaining Respiratory Care and Effective CPR After Tracheostomy Decannulation

Lima, Ohio Survey Completed on 03-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary life-sustaining respiratory services and effective CPR to a ventilator-dependent resident with a tracheostomy. The resident had diagnoses including acute and chronic respiratory failure, ventilator dependence, obstructive sleep apnea, pulmonary hypertension, and malnutrition, and was documented as a Full Code receiving invasive ventilation via a tracheostomy cannula. Her care plan included interventions to ensure trach ties were secured, to keep an extra trach cannula and obturator at the bedside, and a specific "cannula out" procedure directing staff to open the stoma with a hemostat, attempt reinsertion, monitor for respiratory distress, elevate the head of the bed, stay with the resident, and obtain medical help immediately if reinsertion was not possible.

On the night of the incident, an agency LPN was assigned to the resident’s care. The LPN later reported she had not previously worked with the facility’s ventilator residents, had not been oriented to the unit or to the resident’s care plans, and had not received education on tracheostomy care, decannulation procedures, or the location of emergency equipment such as the crash cart and Ambu-bag. A CNA alerted the LPN that the resident’s trach had come out while care was being provided. When the LPN entered the room, she found the tracheostomy cannula lying on the resident’s chest and the resident unresponsive. The LPN attempted to reinsert the cannula but was unsuccessful, instructed the CNA to call the respiratory therapist and 911, and then began chest compressions when she could not obtain a pulse. During this period, the LPN did not provide supplemental oxygen and verified she did not know where the crash cart or Ambu-bag were located.

The respiratory therapist, who had left the building at midnight after providing earlier trach and ventilator care and documenting that the resident was stable, was called back and arrived with EMS. Upon arrival, the respiratory therapist found the resident completely decannulated, very dusky, and with the LPN performing chest compressions but not providing oxygen via Ambu-bag or any other means. The respiratory therapist was able to reinsert the trach cannula, independently located the Ambu-bag in the gray basket on the ventilator, connected it to oxygen, and began ventilating the resident through the trach while EMS took over compressions. EMS documentation indicated that staff at the facility were unable to provide a history or information about the resident and that no information packet accompanied the resident to the hospital. Hospital records documented that the resident arrived in cardiac arrest secondary to hypoxic respiratory failure after the trach had been out for an undisclosed period of time, with initial blood gases showing respiratory acidosis and a clinical picture consistent with hypoxic respiratory failure leading to cardiac arrest. The death certificate listed anoxic brain injury secondary to cardiac arrest and hypoxic respiratory failure as the cause of death.

Additional interviews and observations supported that staff were not adequately trained or prepared to manage tracheostomy emergencies. The agency LPN repeatedly told the respiratory therapist and EMS that she did not know where anything was for the resident or how to care for the trach when it became dislodged, despite having current CPR certification. The respiratory therapy manager confirmed there was no official training for agency nurses on caring for residents with tracheostomies on ventilators and stated that guidance was only contained in the care plans. A resident interview indicated awareness that a ventilator-dependent resident had died and that staff working that night were not trained to care for ventilator residents, and that there were no respiratory therapists in the building at night. Policy review showed that the facility’s CPR policy required provision of breaths via Ambu-bag after compressions, and the decannulation policy required calling 911, calling for a crash cart, attempting to reinsert the trach or establish an airway, and using an Ambu-bag with oxygen if there were no spontaneous breaths. Despite these written procedures and the presence of emergency supplies such as Ambu-bags and crash carts in the building, they were not effectively used during the resident’s decannulation and cardiac arrest, resulting in the identified deficiency.