F0840

G

Failure to Secure ENT Evaluation for Resident With Tracheostomy and Tracheal Stenosis

Provo, Utah Survey Completed on 03-16-2026

Penalty

Fine: $27,471

Summary

The facility failed to obtain outside professional ENT services for a resident when it did not employ a qualified professional to provide the required service. The resident was admitted with chronic respiratory failure, tracheostomy status, pneumonia, and anoxic brain damage. Hospital records documented that the resident previously had a tracheostomy exchange by ENT due to hemoptysis, experienced a respiratory arrest with a dislodged trach, and had significant subglottic and proximal tracheal stenosis. ENT had recommended against trialing a Passy Muir Valve and advised changing the trach every three months. A physician order for an ENT referral related to stenosis and tracheostomy status was initiated, and a later nurse practitioner note documented the need for follow-up with ENT for subglottic and tracheal stenosis.

The Transportation Driver documented that an order for the ENT visit was received and sent to the ENT office, but the office reported the resident did not have insurance and would require self-pay, and therefore would not schedule the appointment without confirmation from the family. The Transportation Driver reported multiple unsuccessful attempts to contact the family and did not secure an appointment. The Business Office Manager stated the resident was Medicaid pending, that she had been in contact with Medicaid since admission, and that if an outside provider would not accept a Medicaid pending resident, the facility would be responsible for payment. The Business Office Manager also stated she was not informed that the ENT provider would not see the resident due to Medicaid pending status and that, had she known, she would have discussed payment with the Administrator so the resident could be seen by ENT. As a result, the resident did not receive the ordered ENT evaluation for tracheostomy and tracheal stenosis.