Failure to Provide Safe Tracheostomy and Respiratory Care Resulting in Resident Deaths
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory and tracheostomy care in accordance with physician orders, professional standards, and resident-specific limitations. For one ventilator-dependent resident with chronic respiratory failure, tracheostomy status, pneumonia, anoxic brain damage, and documented subglottic and proximal tracheal stenosis, hospital records indicated that ENT had changed the trach in the OR and recommended trach changes every three months instead of monthly, and advised against trialing a Passy Muir Valve. A nurse practitioner note directed continued trach care per RT protocol with ENT follow-up for the stenosis. The DON reported seeing a provider note indicating the trach should be changed every three months, but this order was never entered into the medical record. The prior standing order to change the trach every 45 days had been converted to every 30 days by the contracted respiratory company, and then the trach change order dropped off the MAR in January, leaving no active order for trach changes at the time of the resident’s death. On the day of the event, RT documentation earlier in the day described the resident as alert and oriented, on a ventilator with an XLT cuffed, non-fenestrated size 7 trach, with the trach midline, secure, and patent, and no signs of respiratory distress. Later, an RT note documented that the RT performed a trach change because the resident reported the trach was too tight that morning. The RT pre-oxygenated the resident and recorded stable SpO2 and HR before the attempt. During removal and reinsertion of the trach tube, resistance was encountered and insertion was unsuccessful; a smaller trach was then attempted and also could not be inserted. The resident developed acute respiratory distress with pallor and cyanosis, oxygen saturation dropped, and a code blue was initiated. Nursing documentation corroborated that during the attempted trach change, resistance was met twice, the resident became cyanotic with decreasing oxygen saturation, and CPR was initiated after the resident was found unresponsive, apneic, and pulseless. EMS continued resuscitative efforts, and the resident was pronounced dead. Interviews revealed that RT 1 believed the resident’s complaint of tightness meant the trach needed to be changed immediately, pushed a partially dislodged trach back in earlier that morning, and then proceeded with a trach change despite the resident not being in distress and the trach being described as secure, patent, and midline. RT 2 stated he was unaware the trach was not supposed to be changed and had never changed a vented patient’s trach before. RT 3 stated there were instructions that the resident’s trach was not to be changed until seen by ENT, and that he had seen the resident’s name on a whiteboard with an “ENT only” notation. The RT Director stated she had received a verbal order that the trach should be changed only by ENT unless emergent, but this was not entered into the chart and was only communicated verbally and on a whiteboard. A second resident with anoxic brain damage, acute and chronic respiratory failure, tracheostomy status, and pneumonia due to pseudomonas experienced a fatal event related to a broken trach flange and trach displacement. A late-entry RT note documented that during first rounds at night, the RT found the trach tube broken and dislodged from the flange, with the tube about 1.5 inches out of position and deviated from midline. The RT called a nurse and another RT to assist, removed the old tube, and inserted a new Shiley XLT 6 that had been tested and lubricated. During suctioning, a significant amount of blood was observed, and repeated suction passes continued to remove blood. The SpO2 alarm indicated low oxygen saturation, the resident was disconnected from the ventilator for manual bagging, and SpO2 did not improve. A pulse check revealed no pulse, the resident was transferred to the floor, a smaller XLT 5 trach was placed without resistance, and manual ventilation and chest compressions continued until EMS arrived, but the resident could not be revived. A nursing late entry confirmed that the RT showed the nurse the broken trach, that vital signs were stable before the change, and that copious bleeding occurred during the trach change, followed by code blue and unsuccessful resuscitation. RT 4 reported that the trach was broken at the flange and deviated at a 45-degree angle, that the ventilator was not alarming despite the deviation, that the resident’s lips appeared cyanotic with SpO2 below 90%, and that he changed the trach to restore a patent airway. He described large amounts of frank blood and mucus on suctioning and believed the airway was filled with blood. RT 4 also reported concerns about ventilator alarms, pulse oximeters, alarm cables, and lack of needed supplies prior to the current RT Director’s tenure, and stated he had asked repeatedly for alarms, pulse oximeters, and cables. A third resident with quadriplegia, anoxic brain damage, and chronic respiratory failure with hypoxia and hypercapnia had orders related to BiPAP/ventilator use, including checking body positioning, nasal cannula placement, and BiPAP vent settings with humidity. The overall deficiency cited that staff did not follow physician orders for changing tracheostomies, did not obtain needed consultations with outside providers, did not accurately document resident condition prior to trach changes, and did not initiate hospital transfer when there were concerns about trach integrity. Staff interviews revealed knowledge of faulty trach equipment, including broken flanges that caused trach dislodgement, and that one resident with a broken flange and dislodged trach went into cardiac arrest and died. Additionally, another resident with displaced BiPAP was found unresponsive, CPR was initiated, and the resident could not be resuscitated and died. These failures in respiratory and tracheostomy care for multiple residents resulted in findings of immediate jeopardy for two of the residents.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident who required oxygen therapy for SOB had an oxygen bubbler that was overdue for replacement, despite a TAR directing weekly changes of oxygen supplies including the bubbler and tubing. Staff confirmed the bubbler should have been changed weekly, and the DON and staff educator stated nurses were expected to follow the provider order as written and that all disposable oxygen pieces were to be changed weekly.
A resident with COPD, acute respiratory failure with hypercapnia, and oxygen dependence was admitted with prior records showing nightly Bi-pap use and specific settings, but the facility did not have a Bi-pap order or settings in the chart and the baseline care plan did not address oxygen or Bi-pap. The resident reported he went without Bi-pap for three nights because a connector piece was missing, while the hospice RN, admitting LPN, ADON, and DON each stated they were unaware of the machine or did not verify the equipment and orders at admission.
Respiratory care was not provided as ordered for one resident receiving O2, as the NC tubing was not dated. Tracheostomy care was also not provided as ordered for another resident: heavy thick mucus was visible under the trach, the ATM mask was soiled with mucus, the ATM and nebulizer tubing were not dated or stored in a bag, and the suction catheter tubing end was not stored in a bag. An RN confirmed the findings.
The facility failed to follow physician orders for oxygen equipment for two residents with COPD-related diagnoses. Observations showed each resident’s O2 tubing and water bottle remained dated and unchanged beyond the ordered weekly schedule, and the DON confirmed the equipment should have been changed per the orders.
Failure to maintain ordered continuous O2: A resident with stroke and COPD was observed without his NC while a CNA waited for a portable O2 unit to be filled. The CNA then applied the NC but did not turn on the liquid portable O2, and later wheeled the resident to the nurse’s station to have the nurse set the unit to the ordered liter flow. The resident’s physician had ordered continuous O2 2L to 4L NC.
Improper Storage of CPAP Mask and Oxygen Tubing: A resident with COPD, DM, dialysis dependence, and continuous O2 orders had his CPAP/NIV mask observed lying on the bedside table and his O2 tubing wrapped under the concentrator handle instead of being stored in a sanitary container or bag. Staff interviews confirmed the equipment should be stored in a bag when not in use, but it was not being kept that way during observation.
Oxygen equipment not maintained per order
Penalty
Summary
The facility failed to ensure respiratory equipment was properly maintained for one resident who required oxygen therapy. The resident was cognitively intact, had diagnoses including multiple sclerosis and hypoxemia, and the care plan identified shortness of breath related to the diagnoses with oxygen therapy required. The August 2026 TAR directed staff to change oxygen supplies, including the oxygen bubbler and tubing, and to date and initial the change every night shift every Wednesday for routine exchange and maintenance. During observation, the resident was in bed receiving oxygen through a nasal cannula, and the oxygen PM bubbler was dated 6/4/26. RN-A stated the oxygen tubing and bubbler were supposed to be changed weekly and confirmed the bubbler date was overdue, stating it should have been changed. RN-A also stated that if oxygen supplies were not maintained properly, the chance of contracting respiratory infection increased. RN-B, who was also the staff educator, stated nurses were expected to follow provider orders as written, and the DON stated nurses should follow orders as written and that the bubbler should have been changed weekly. Facility policy stated all oxygen equipment should be clean, safe, and functional and all disposable pieces changed weekly.
Bi-pap Therapy Not Ordered or Verified at Admission
Penalty
Summary
The facility failed to ensure respiratory care was provided consistently with professional standards of practice for Resident #56, who had diagnoses including acute respiratory failure with hypercapnia, COPD, cerebral infarction, and dependence on supplemental oxygen. The resident’s prior records sent to the facility before admission documented that he required Bi-pap therapy at night for chronic hypercapnic respiratory failure, with specific settings listed, and that frequent monitoring of respiratory status, oxygen saturation, and adherence to Bi-pap therapy was critical. However, the facility’s baseline care plan did not address supplemental oxygen use or Bi-pap use, and the facility’s order summary showed oxygen at 2 to 4 liters per nasal cannula but no Bi-pap order. The resident told surveyors that he used the Bi-pap machine every night for 5 to 6 hours, but he was unable to use it for three nights because he could not find the connector piece needed to make the machine work. He stated he did not tell facility staff about the missing piece and instead told the hospice RN. During the observation, he was sitting in a wheelchair on oxygen at 3 liters per nasal cannula, with even and unlabored respirations and no shortness of breath. Nursing notes during the stay documented oxygen saturations ranging from 94% to 98% while on oxygen, but the records did not show a Bi-pap order or settings in the hospice orders. Interviews showed that the hospice RN who admitted the resident was not aware he had a Bi-pap machine and did not see it in the facility, and she did not review the DME section of the chart. The admitting LVN and ADON both stated they were unaware of the Bi-pap machine or its missing order/settings, and neither checked whether the equipment was present and working at admission. The DON stated she assumed hospice would write the Bi-pap order and later learned there were no orders for the machine. The Administrator stated the admission nurse was responsible for verifying equipment was in proper working condition and that all needed services and orders were administered. The facility policy on CPAP/Bi-pap described how to use the machine and to contact the DME company if it was not operating correctly, but it did not indicate that orders were required.
Respiratory Care and Tracheostomy Care Not Provided as Ordered
Penalty
Summary
Respiratory care was not provided consistent with professional standards of practice for a resident receiving oxygen. The resident had diagnoses including depression, low blood pressure, and atrial fibrillation, and the MDS indicated oxygen therapy while a resident. During observation, the resident was lying in bed with oxygen on, and the nasal cannula was not dated. The physician order required oxygen at 3 liters per minute via nasal cannula at night or as needed, and another order directed that the oxygen concentrator and filter be cleaned and the tubing changed weekly. During interview, the RN confirmed that the oxygen tubing did not have a date on it and confirmed the facility failed to provide appropriate respiratory care for the resident. Tracheostomy care was also not provided consistent with professional standards of practice for another resident. The resident had diagnoses including diabetes, heart failure, and stroke. Physician orders directed staff to check that the trach mask and oxygen were in place and to assess the need for suctioning, trach care, and oral care four times a day. The care plan directed suctioning of the trach and oral care every shift and every two hours as needed, and to provide oxygen via aerosolized trach mask with tubing and filters changed weekly. During observation, the resident was connected to oxygen via ATM, but heavy thick mucus was visible under the trach, the inside of the trach mask was soiled with mucus, the ATM tubing and nebulizer tubing were not dated, and the tubing was not stored in a bag as required. The suction catheter tubing end was also not stored in a bag as required, and the RN confirmed these findings during interview.
Failure to Change Oxygen Equipment per Physician Orders
Penalty
Summary
The facility failed to maintain respiratory equipment according to physician orders for two residents receiving oxygen therapy. Resident R18 had diagnoses including chronic respiratory failure, COPD, and hypertension, and had an order dated 10/20/25 to change the O2 tubing, water bottle, and tubing bag weekly every Sunday night shift. Resident R20 had diagnoses including COPD, GERD, and hypothyroidism, and also had the same weekly order for oxygen tubing, water bottle, and tubing bag. Facility policy stated medications are to be administered in accordance with written physician orders. On 8/4/26 and again on 8/5/26, observations showed both residents’ oxygen concentrators with water bottles and O2 tubing dated 7/27/26. The dated equipment remained unchanged during the second observation. During interview on 8/5/26, the DON confirmed that both residents’ water bottles and oxygen tubing were dated 7/27/26 and should have been changed per physician orders.
Failure to Maintain Ordered Continuous Oxygen
Penalty
Summary
The facility failed to ensure that Resident #6 received continuous oxygen via nasal cannula as ordered by the physician. The facility’s Oxygen Administration policy dated February 2024 stated staff were to verify a physician’s order and place the appropriate oxygen device on the resident, with oxygen started at the ordered flow rate. Resident #6 was admitted and later readmitted to the facility with diagnoses including stroke and COPD, and the physician’s order dated 6/25/26 specified oxygen 2L to 4L NC continuous. On 8/3/26 at 10:17 AM, Resident #6 was observed sitting in a wheelchair in his room without his oxygen cannula on while CNA #1 stood next to him. CNA #1 stated he was taking Resident #6 out of the room but was waiting for the portable oxygen unit to be filled. When the liquid oxygen unit arrived, CNA #1 attached the tubing and applied the nasal cannula but did not turn on the portable oxygen unit. At 10:26 AM, CNA #1 wheeled Resident #6 to the nurse’s station and waited for the nurse to turn the portable oxygen on to the resident’s liter flow. The resident’s care plan documented oxygen as ordered and to check room air saturation as ordered, wean as able/ordered. On 8/4/26 at 4:40 PM, the RNC stated the CNA should not have taken Resident #6 off oxygen and should have had the nurse set the liquid portable unit to the proper liter flow before placing it on the resident.
Improper Storage of CPAP Mask and Oxygen Tubing
Penalty
Summary
The facility failed to ensure Resident 10’s CPAP/NIV mask and oxygen tubing were stored in a sanitary manner. Resident 10 had diagnoses including DM, COPD, dialysis dependence, and dependence on supplemental oxygen. His record included physician orders for NIV use at night with oxygen at 3 LPM connected to the device, and oxygen at 3 LPM via nasal cannula after the mask was removed in the morning. The resident’s MDS documented a BIMS score of 15, indicating intact cognition, and his care plan included staff assistance with respiratory equipment as ordered. During observation, the resident’s NIV mask was seen lying directly on the bedside table next to the machine rather than in a container. On another observation, the resident’s oxygen tubing was wrapped together and placed under the handle of the oxygen concentrator instead of being stored in a container. A CNA stated she would transfer the oxygen tubing from the concentrator to the portable oxygen tank after getting the resident up and then place the tubing inside the concentrator handle. An LN stated the CPAP mask and oxygen tubing should be stored in a bag when not in use, and an Administrative Nurse stated the respiratory equipment should be cleaned and changed as ordered and stored in the dated bag.
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