F0610

G

Failure to Investigate Broken Tracheostomy Incident Leading to Resident Death

Provo, Utah Survey Completed on 03-16-2026

Penalty

Fine: $27,471

Summary

The deficiency involves the facility’s failure to thoroughly investigate an alleged violation related to a serious incident involving a ventilator‑dependent, comatose resident with a tracheostomy. The resident had diagnoses including anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas. On the evening in question at 9:00 PM, respiratory staff entered the resident’s room and found the tracheostomy flange broken, with the tracheostomy tube dislodged and approximately 1.5 inches out of position, shifted to the right and not midline. Respiratory therapy staff notified nursing and called a second respiratory therapist to assist with a tracheostomy tube change. During suctioning, respiratory staff observed a significant amount of blood and performed additional suction passes due to continued accumulation of blood.

As the event progressed, the resident’s oxygen saturation dropped, and respiratory staff initiated manual ventilation, but oxygen levels did not improve. Nursing staff performed a pulse check, found no pulse, and the resident was lowered to the floor where CPR was initiated. EMS arrived, but the resident could not be revived and died. In a subsequent interview, the DON stated that staff had identified the broken tracheostomy and decided to change it, that increased bleeding occurred, and that the resident went into cardiac arrest, leading to CPR and EMS involvement. The DON further stated she had not investigated how the tracheostomy broke and was unsure whether the respiratory therapy director at the time had conducted any investigation, demonstrating that the facility did not have evidence that the alleged violation was thoroughly investigated.