F0695

J

Failure to Provide Safe Tracheostomy and Respiratory Care Resulting in Resident Deaths

Provo, Utah Survey Completed on 03-16-2026

Penalty

Fine: $27,471

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.