Failure to Report Tracheostomy-Related Injury and Death to SSA and APS
Penalty
Summary
The facility failed to ensure that an alleged violation involving an injury of unknown source was reported immediately, but no later than 2 hours after the allegation was made, to the administrator, State Survey Agency (SSA), and Adult Protective Services (APS). For one resident with anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas, the tracheostomy flange was found broken and the tracheostomy tube dislodged. A respiratory therapist documented that around 9:00 PM, during first rounds, the tracheostomy tube was observed broken and approximately 1.5 inches out of position, requiring immediate replacement. During the trach change, significant bleeding was noted, multiple suction passes were performed, the resident’s SpO2 alarmed low, and manual bagging was initiated. Despite these interventions, the resident’s SpO2 did not improve, no pulse was detected, chest compressions were started, and EMS later took over. A nursing late entry note documented that the RT called the nurse into the room, showed that the trach was broken and needed replacement, and that another RT was called to assist. At that time, the resident’s oxygen and other vital signs were stable. The RTs then alerted the nurse to copious bleeding during the trach change, after which the resident became unstable, a code blue was initiated, additional staff arrived, 911 was called, and the resident could not be revived, with time of death pronounced. Review of SSA records showed the incident was not reported. In interviews, the DON stated that night shift respiratory staff identified the broken trach and changed it, that there was increased bleeding and the resident went into cardiac arrest, and that the incident was not reported to the SSA because it was believed staff followed policy and there was no concern for negligence. The DON also stated she was unsure how the trach broke and was unsure if the respiratory director investigated the incident, and that she and the Administrator decided not to report the event because they believed respiratory staff followed policy when changing the broken trach.
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