Failure to Provide Safe Tracheostomy Respiratory Care and Monitoring
Summary
The deficiency involves multiple failures in providing safe and appropriate respiratory care, particularly for residents with tracheostomies, including one resident who died after a tracheostomy dislodgement. One resident with toxic encephalopathy, respiratory failure with tracheostomy collar, and hemiplegia had a physician order for high-flow O2 at 20 L/min via trach collar and continuous pulse oximetry. On the day of the incident, an LPN observed this resident with oxygen tubing connected to the trach tubing on the resident’s finger but documented no intervention to prevent dislodgement, despite the resident’s impaired cognition and care plan indicating the resident rarely or never understood redirection. Later that afternoon, a respiratory therapist found the trach tube dislodged and attempted reinsertion, while CPR was documented as starting within about a minute of that time and 911 was called shortly thereafter. Paramedic documentation states the crew arrived to find the resident unresponsive, pulseless, and apneic, with staff attempting to reinsert the trach, and noted facial and tongue swelling that prevented intubation; the resident was pronounced dead. The facility did not complete an incident report or investigation for this death and did not report it to the State agency, with the nurse consultant characterizing it as a medical case despite the facility’s own policy requiring reporting of accidents or incidents with injury or potential for injury, including deaths due to accidents. The report also identifies failures in staff competency and training related to tracheostomy and respiratory care. The LPN assigned to the deceased resident stated she did not know the resident’s oxygen requirements, was unfamiliar with ABG and FiO2 changes, and reported receiving no respiratory or trach-specific training at the facility. Human resources records for this LPN and another LPN showed that required nursing skills competency evaluations, including orientation elements such as nursing procedures and multiple specific competencies (e.g., hand hygiene, IV piggyback, PPE, policy review), were not completed; the forms were only signed and dated by the nurses without documented evaluation. The DON confirmed there were no trach care or respiratory care trainings and described onboarding evaluation as a process to identify training needs, but no trach-specific competencies were documented. Staff interviews indicated that RT coverage for trach residents had been reduced, and that nurses, rather than RTs, were responsible for some trach patients, with RTs not performing CPR. Additional deficiencies were found in assessment, monitoring, and equipment readiness for residents with tracheostomies. The facility lacked an initial assessment process specific to trach residents to determine acuity and levels of care, as acknowledged by the DON. For the deceased resident, the care plan and orders required continuous pulse oximetry and oxygen saturation monitoring, yet there was no oxygen saturation documentation on the day of death in the vital sign history, and the MAR showed only a single oxygen saturation entry for that day with no vital signs documented in clinical notes. Observations on the respiratory unit showed multiple residents with trachs lacking required bedside equipment per the facility’s “Reinsertion of Tracheostomy Tube with Accidental Extubation” policy, including missing spare trach tubes, sterile 4x4s, tape, and nonfunctional or disconnected pulse oximeters. Staff acknowledged defective or disconnected pulse oximeters and incomplete supply setups, and in one case a nurse believed an Airvo high-flow device was a ventilator and found it turned off while the resident was ordered to receive high-flow O2. The report further documents failure to follow physician orders for trach care and suctioning for another resident, who was initially admitted without infection and later developed respiratory infection and pneumonia. This resident had orders for trach care, inner cannula changes, and suctioning at specified frequencies, but the treatment administration record showed multiple missed entries for trach care, inner cannula cleaning and changing, and scheduled suctioning across several days. The infection preventionist and a physician stated that trach care, suctioning, and inner cannula changes are intended to clear mucus, maintain airway patency, limit bacterial growth, and reduce infection risk, and that missed care increases the risk of infection. This resident was subsequently sent to the hospital for difficulty breathing and infection, with hospital records noting tachycardia, tachypnea, leukocytosis, chest x-ray with superimposed pneumonitis, and tracheal cultures positive for organisms associated with pneumonia and sepsis. These documented omissions in ordered trach care and suctioning, combined with the lack of respiratory assessments and incomplete documentation, formed part of the cited deficiency. The surveyors determined that these failures constituted an immediate jeopardy beginning when the trach-dependent resident was pronounced dead after being found unresponsive, pulseless, and apneic following trach dislodgement. The facility’s own leadership acknowledged that residents at risk of trach dislodgement should not be left alone and that trach dislodgement can result in low oxygen, confusion, altered mental status, or death, yet there was no trach-specific acuity assessment, no documented respiratory assessments, and incomplete monitoring for the affected residents. The combination of inadequate monitoring, lack of staff competency evaluation and training, failure to maintain functional and complete emergency trach equipment at the bedside, failure to follow physician orders for trach care and suctioning, and failure to report and investigate the death related to trach dislodgement formed the basis of the cited respiratory care deficiency for multiple trach-dependent residents. The nursing home is disputing this citation, but the report documents that eight of eleven reviewed residents with tracheostomies were affected by one or more of these failures, including the resident who died after trach dislodgement, several residents lacking required trach reinsertion equipment or functional monitoring devices, and one resident who developed respiratory infection and pneumonia in the context of missed trach care and suctioning orders. The survey findings are based on interviews with staff and family, review of clinical records, physician orders, hospital records, death certificate, and direct observations of residents and equipment on the respiratory unit.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Two residents receiving O2 had flow rates set above their physician orders, and one resident’s tubing remained dated beyond the weekly change interval. Staff, including an RN and the DON, confirmed the mismatched flow rates and noted that tubing should be changed weekly by the RT. The facility policy required O2 to be administered per physician order and tubing/cannula to be changed weekly.
Oxygen Concentrator Left in Room After Order Discontinued: A resident with morbid obesity with alveolar hypoventilation and diabetes was observed with an oxygen concentrator at bedside even though there was no current oxygen order. The resident stated he used oxygen only when needed, and the CNO confirmed the oxygen had been discontinued earlier and the concentrator should not have remained in the room.
Missing Order for CPAP Use and Maintenance: A resident with sleep apnea and stroke had a CPAP in the room, but there was no physician order or care plan documentation for its use or maintenance. Staff knew the resident had the CPAP, yet CNAs and an RN reported they did not routinely clean the mask or tubing, and the LPN Resident Care Manager confirmed no order existed for the CPAP or its care.
A resident with a continuous O2 order was found without oxygen in place, and an LPN later said the order had been misread. Two other residents with COPD had respiratory equipment that was dirty or outdated, including a gray concentrator filter, tubing and water bottles dated weeks earlier, and tubing lying on the floor with visible dust. Staff gave inconsistent accounts of who was responsible for changing or cleaning the equipment, and the DON acknowledged the dirty equipment and old mask placed residents at risk for respiratory infection or pneumonia.
A resident with acute respiratory failure with hypoxia and severe cognitive impairment was ordered oxygen via NC at 2 to 5 LPM to keep O2 saturation at or above 95%. During observation, the resident was lying in bed with the NC on the side of the face instead of in the nose while the concentrator was set at 2.5 LPM. RN and DON stated the NC should be in the nose to deliver oxygen as ordered.
A resident with COPD and chronic respiratory failure did not receive oxygen at the ordered flow rate. Staff found the oxygen concentrator set below the ordered amount on multiple observations, and the resident stated the oxygen was supposed to be set higher. The DON, LVNs, and ADON acknowledged the setting was incorrect and that the ordered flow should have been followed.
Incorrect Oxygen Flow Rates and Delayed Tubing Changes
Penalty
Summary
The facility failed to provide respiratory care consistent with physician orders for two residents receiving oxygen therapy. Resident #5 had an order dated 1/7/2025 for oxygen at 2 liters via nasal cannula continuously for infiltrate of the left lung, but during observations on 7/7/2026, 7/8/2026, and 7/9/2026 the resident’s oxygen was running at 3 liters per minute. On 7/7/2026 and 7/8/2026, the oxygen tubing in Resident #5’s room was dated 6/26, and on 7/9/2026 Staff F, RN confirmed the tubing date and the 3-liter flow rate. Staff F stated the tubing should have been changed the prior week and that the resident was running at 3 liters despite an order for 2 liters. Resident #6 had a physician order dated 3/18/2026 for oxygen at 3 liters via nasal cannula continuously for chronic respiratory failure with hypoxia, but during observations on 7/7/2026 at 10:10 AM and 12:12 PM, and again on 7/8/2026 at 8:02 AM, the resident’s oxygen was being administered at 4 liters per minute. On 7/9/2026 Staff F, RN entered the room and confirmed the oxygen was at 4 liters, stating it should not be at that rate because the order was for 3 liters. The DON stated nursing staff should check oxygen flow rate every shift and as needed, and that tubing should be changed weekly by the respiratory therapist. The facility policy also stated oxygen tubing and mask/cannula are to be changed weekly and as needed if soiled or contaminated.
Oxygen Concentrator Left in Room After Order Discontinued
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not maintained when the facility failed to remove an oxygen concentrator from Resident #12's room after the physician discontinued the oxygen order. Resident #12 was admitted and later readmitted to the facility with diagnoses including morbid obesity with alveolar hypoventilation and diabetes. On 7/7/26, the resident was observed sitting in his power chair with an oxygen concentrator at his bedside. When asked about oxygen use, the resident stated he only used oxygen when he needed it. Review of the resident's physician orders showed no current oxygen order, and the CNO stated on 7/8/26 that the oxygen concentrator should not have been in the room because oxygen had been discontinued on 6/17/26.
Missing Order for CPAP Use and Maintenance
Penalty
Summary
The facility failed to obtain physician orders for the use and maintenance of a CPAP for Resident 76, who was admitted in 6/2026 with diagnoses including sleep apnea and stroke. There was no documentation in the admission MDS or care plan showing that the resident used a CPAP. Observations from 7/6/26 through 7/10/26 showed the CPAP in the resident’s room on the nightstand. The resident stated that a friend brought the CPAP to the facility a day after admission, but staff did not clean the mask or tubing daily and the mask did not fit well. Staff interviews showed the CNA staff were aware of the CPAP but did not clean the mask or hose, one CNA reported washing the mask one time, and an RN stated she filled the chamber with water a few times but did not clean the mask or tubing. The LPN Resident Care Manager confirmed the resident did not have an order for the CPAP or for cleaning and caring for the equipment.
Respiratory Equipment Not Maintained or Applied as Ordered
Penalty
Summary
Resident #12 had an order for oxygen at 2 liters per minute via nasal cannula continuously, with titration up to 4 liters to keep oxygen saturations above 90% every shift. The resident’s care plan also directed staff to apply oxygen at 2 liters via nasal cannula. During an observation, the resident was up in a chair with no oxygen in place. The resident stated she had been wearing oxygen but was not sure when or why staff stopped applying it. The nurse later stated she had misread the order as oxygen could be applied only if saturations fell below 90%, and she acknowledged the resident did not wear oxygen despite the active continuous order. Resident #27 had diagnoses including dementia, COPD, anxiety, and shortness of breath, and her MDS indicated she required oxygen therapy. Her care plan directed staff to change oxygen tubing as needed and nebulizer tubing every week. During multiple observations, the resident’s oxygen concentrator filter was gray and dirty, and the tubing and empty water bottle were dated 5/24/26. The resident stated staff usually changed the equipment, but it had not been changed that she could recall. Later, the tubing and water bottle remained dated 5/24/26, and the concentrator filter was still dirty. Staff interviews reflected uncertainty about who was responsible for changing the equipment, and the ADON stated the tubing and water bottle should have been changed by 07/02/26, while the DON stated the dirty filter and old nebulizer mask placed the resident at risk for respiratory infection or pneumonia. Resident #9 had COPD and an order for oxygen at 2 to 4 liters per nasal cannula to maintain PO2 greater than 90%. The resident’s oxygen tubing was observed lying on the floor and had a piece of tape dated 06/22/26, with brown dust visible in the wheel-mark pattern on the tubing. The resident was unable to state when the tubing was last changed or how often it was changed. Staff interviews showed differing practices about changing oxygen tubing, with some stating it should be changed weekly or when dirty, while the DON stated she had been advised not to date the tubing and to change it when visibly soiled. The facility policy stated cannula or mask needed to be changed if it malfunctions or becomes visibly contaminated.
Oxygen Not Properly Delivered via Nasal Cannula
Penalty
Summary
The facility failed to ensure oxygen was administered in accordance with the physician’s order and facility policy for one sampled resident. Resident 44 was admitted with diagnoses including acute respiratory failure with hypoxia and encephalopathy. The MDS dated 5/28/2026 indicated the resident had severe cognitive impairment, was on oxygen therapy, and was dependent for eating, oral care, toileting, personal hygiene, showering, dressing, and footwear. A physician’s order dated 6/4/2026 directed oxygen via nasal cannula at 2 to 5 LPM to maintain oxygen saturation at or above 95% every shift, and the care plan was revised to reflect humidified oxygen via nasal cannula at 2 to 5 LPM to maintain oxygen saturation at or above 95% every shift. During a concurrent observation on 6/29/2026 at 10:33 AM, Resident 44 was observed lying in bed with the nasal cannula on the left side of the face while the oxygen concentrator was set at 2.5 LPM. During interviews, RN 3 stated the nasal cannula should be placed correctly in the resident’s nose for the resident to receive oxygen, and the DON stated the nasal cannula should always be in the resident’s nose to help maintain oxygen saturation at 95% and above. The facility policy titled Oxygen Administration stated oxygen is administered to residents who need it, consistent with professional standards of practice and comprehensive person-centered care plans, and under physician orders.
Incorrect Oxygen Flow Settings
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for a resident with COPD, chronic respiratory failure, and functional quadriplegia. The resident’s care plan directed that oxygen be administered at 2 L/min via nasal cannula continuously to maintain SPO2 above 90%, and the physician order summary reflected oxygen at 2 L/min via nasal cannula continuously. However, during observation and interview on 06/30/2026, the resident’s oxygen concentration machine was set at 3 L/min, and the resident stated her oxygen was supposed to be set at 4 L/min. The LVN stated the resident was supposed to be on 4 L/min and adjusted the oxygen to 3.5 L/min, and the DON later stated the resident was to be getting 4 L/min and adjusted the setting to 4 L/min. A subsequent physician order dated 07/01/2026 directed oxygen at 4 L/min via nasal cannula to maintain SPO2 above 90%. During observation on 07/02/2026, the resident’s oxygen was again found set at 3.5 L/min. An LVN checking the setting stated it was at 3.5 L/min and that if physician orders were not followed, the resident could become short of breath and the orders would not be followed. The ADON stated the oxygen machine should be set with the ball meter at eye level, that if the order said 4 L/min it should be set on 4 L/min, and that 3.5 L/min was not good enough. The facility’s oxygen administration policy required verifying a physician order and adjusting the oxygen delivery device so the proper flow of oxygen was being administered.
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