F0658

G

Failure to Enter and Follow Tracheostomy Orders Leading to Improper Trach Change

Provo, Utah Survey Completed on 03-16-2026

Penalty

Fine: $27,471

Summary

The deficiency involves the facility’s failure to ensure that respiratory services met professional standards of practice for a resident with chronic respiratory failure, tracheostomy status, pneumonia, and anoxic brain damage. The resident had prior physician orders for tracheostomy tube changes every 45 days and then every 30 days, but these orders were discontinued and no new order to change the tracheostomy tube was entered after a certain date. A hospital H&P documented that the resident’s tracheostomy had been exchanged by ENT due to hemoptysis, that the resident had experienced a dislodged trach with respiratory arrest and PEA, and that ENT recommended against PMV trials and advised trach changes every three months instead of monthly. Despite this, the ENT recommendation was not converted into an active physician order in the resident’s medical record.

On the day of the incident, an RT note documented that the RT performed a trach change because the resident reported that the trach felt too tight. During removal and attempted reinsertion of the trach tube, resistance was encountered and insertion was unsuccessful, even with a smaller size trach. The resident then developed acute respiratory distress with pallor and cyanosis, leading to a Code Blue. A nursing note corroborated that the RTs initiated what they described as a scheduled trach tube change, encountered resistance with two insertion attempts, and that the resident became cyanotic with decreasing oxygen saturation, prompting immediate resuscitative efforts including manual ventilation, CPR, AED application, and EMS involvement, after which the resident was pronounced dead.

Interviews revealed that RT staff and leadership were operating under inconsistent and undocumented directives. RT 1 stated that trach changes were done if the trach was dislodged or if the resident complained, and otherwise the MD changed the trach. RT 3 stated that, due to tracheal stenosis, the resident’s trach was not to be changed until seen by ENT and recalled seeing the resident’s name on a whiteboard labeled “ENT only.” RT 2 stated he was not informed that the trach was not supposed to be changed and believed there were monthly trach change orders, not realizing those orders had expired. The RT Director reported receiving a VO from the provider that the resident’s trach should be changed only by ENT unless emergent, but this VO was never entered into the resident’s chart; instead, it was only communicated verbally and noted on a whiteboard. The DON confirmed that the ENT recommendation for trach changes every three months was never entered as an order and that the prior standing trach change order had dropped off the MAR, leaving the resident without an active trach change order at the time of the event.