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:
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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