F0600

G

Failure to Coordinate Tracheostomy Care and Specialty Access Resulting in Harm and Death

Provo, Utah Survey Completed on 03-16-2026

Penalty

Fine: $27,471

Summary

The deficiency involves the facility’s failure to ensure residents were free from neglect related to tracheostomy management and access to necessary outside specialty care, resulting in harm to two residents. One resident with chronic respiratory failure, tracheostomy status, pneumonia, and anoxic brain damage had physician orders for routine tracheostomy changes that were later discontinued, with no active order for trach changes at the time of death. An ENT referral was ordered due to subglottic and proximal tracheal stenosis, and the hospital H&P documented that ENT had changed the trach in the OR and recommended trach changes every three months instead of monthly, and against use of a Passy Muir Valve. A nurse practitioner note referenced continued trach care per RT protocol and follow-up with ENT, but the ENT appointment was never obtained. The transportation driver later documented that the ENT office would not schedule because the resident had no insurance and would be self-pay, and that repeated attempts to reach the family were unsuccessful; however, the business office manager stated that the resident was Medicaid pending and that, if an outside provider would not accept that status, the facility would be responsible for payment, and she was not informed of any barrier to the ENT visit.

On the day of the first resident’s death, RT documentation earlier in the day showed the trach as midline, secure, and patent, with stable vital signs and no respiratory distress. Later, RT 1 documented attempting a scheduled trach change after the resident complained the trach was too tight, pre-oxygenating the resident, and then encountering resistance when removing and reinserting the trach tube; a smaller size trach was also unsuccessfully attempted. The resident developed acute respiratory distress with pallor and cyanosis, and a code blue was initiated. Nursing documentation described that during the attempted trach change, resistance was met twice, the resident exhibited respiratory distress with decreasing oxygen saturation and cyanosis, and manual ventilation and CPR were initiated, but the resident was ultimately pronounced dead by EMS. RT 1 reported that the resident had complained of tightness, that the trach appeared dislodged about 1.5 inches from the stoma earlier, and that she pushed it back in; she stated that complaints of tightness could indicate the trach was dirty and needed immediate change, and that she attempted the change with RT 2 assisting, met resistance with both the original and a smaller trach, and then the resident’s oxygen saturation dropped significantly before cardiac arrest. RT 2 stated he did not know the trach was not supposed to be changed and had never changed a vented patient’s trach before; he also noted that he learned only after the death that the physician was supposed to change the trach and that prior monthly trach-change orders had expired.

Additional interviews revealed conflicting and incomplete communication about trach-change orders and ENT-only status. RT 3 stated that due to tracheal stenosis, the resident’s trach was not to be changed until seen by ENT, that he had seen the resident’s name on a whiteboard with a note stating “ENT only,” and that he would not change an ENT-only trach if it was patent, midline, and secure. The RT Director reported receiving a verbal order from the provider in early February that the resident’s trach should be changed only by ENT unless in an emergent situation, but acknowledged this order was never entered into the resident’s chart; she said it was communicated verbally to staff and written on a whiteboard as “trach change on hold until otherwise notified.” The DON stated she had seen a provider note indicating the trach should be changed every three months, but that this order was never placed in the medical record, and that the prior 45-day trach-change order had been changed to every 30 days by the contracted respiratory company and then dropped off the MAR in January, leaving no active trach-change order. The facility’s trach-change policy required changes per doctor’s orders or every 30 days, including emergency changes for damaged or non-patent tubes, and outlined steps for managing inadequate airflow and failed reinsertion, including manual ventilation and calling emergency services.

The second resident involved in the deficiency had anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas, and was comatose and in a vegetative state. Respiratory staff entered the resident’s room in the evening and found the trach flange broken, with the trach tube dislodged about 1.5 inches out of position, shifted to the right, and not midline. RT 4 stated that trachs should be centered and midline to avoid airway obstruction or bleeding, and that the ventilator was not alarming despite every breath being pressurized. The resident’s lips appeared cyanotic, and when the oxygen sensor was repositioned, the saturation was below 90%. RT 4 called for another RT and a nurse, determined the trach needed to be changed to ensure a patent airway, and changed the trach and suctioned the airway. On the first suction pass, a large amount of frank blood and mucus was removed, and two additional passes continued to yield large amounts of blood. The resident’s oxygen remained low, a nurse checked for a pulse and found none, the resident was lowered to the floor, and CPR was initiated while RT 4 continued suctioning large amounts of blood, stating he believed the airway was filled with blood. EMS arrived, but the resident could not be revived and died. The DON confirmed that respiratory staff had identified a broken trach and decided to change it, that there was increased bleeding, and that the resident went into cardiac arrest and passed away, and stated she did not know how the flange broke and was unaware of other residents with broken trach flanges.