Failure to Integrate Respiratory-Related Deaths and Tracheostomy Incidents into QAPI and Required Reporting
Penalty
Summary
The deficiency involves the facility’s failure to use its QAPI and QAA processes to identify, report, investigate, analyze, and prevent adverse events related to three respiratory‑related resident deaths, and to document corrective actions. Surveyors found that the facility did not include all three deaths, particularly one resident’s death, in its QAPI review despite the events involving serious clinical issues with ventilators and tracheostomies. Two residents on ventilators experienced critical tracheostomy events: in one case, respiratory staff changed a tracheostomy when they were not supposed to, and in another, a tracheostomy flange broke, causing the tracheostomy to become dislodged. Both residents went into cardiac arrest and died. The facility also failed to ensure residents had access to outside provider appointments for tracheostomy care and did not follow verbal orders for tracheostomy changes. The report further notes that the facility did not ensure residents were free from neglect and did not meet reporting requirements for incidents involving serious bodily injury. For two residents, the facility did not provide access to outside tracheostomy care as ordered, and verbal orders for tracheostomy changes were not followed. One comatose resident in a vegetative state experienced a broken tracheostomy flange, resulting in a dislodged tracheostomy, cardiac arrest, and death. For this same resident, the State Survey Agency and Adult Protective Services were not notified when the tracheostomy flange broke and the resident died, despite the requirement to report such events within two hours. During interview, the Administrator stated that deaths were reviewed in QAPI with a focus on staff adherence to procedure and reported that residents associated with the immediate jeopardy events had been addressed in QAPI, but one resident’s death had not been reviewed. The Administrator also stated he was not informed of one resident’s death and the broken flange until the following morning and indicated that the contracted respiratory company was responsible for respiratory equipment and had not reported any equipment issues.
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