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:
Surveyors observed four full O2 cylinders on one nursing unit stored unsecured directly on the floor under a sign labeled "FULL CYLINDERS" instead of in a secured storage rack. The ADON confirmed the cylinders were full and should not be on the ground. Reference to NFPA 99 showed that freestanding cylinders must be protected from damage and properly chained or supported in a stand or cart. The DON and Maintenance Director both acknowledged that O2 cylinders are required to be stored in a secure rack, should never be on the floor, and that unsecured cylinders on the floor present a safety risk.
A resident with severe cognitive impairment and COPD, receiving oxygen therapy via nasal cannula, was observed twice with the cannula lying on the floor beside the bed instead of stored in the bag on the oxygen concentrator as required. A CNA later picked up the cannula from the floor, wiped it with a non-disinfectant incontinent wipe, and reapplied it to the resident, despite having been trained that a cannula found on the floor should be replaced. An LVN, the DON, and the Administrator all confirmed that oxygen cannulas must be stored properly, replaced if found on the floor, and that incontinent wipes are not disinfectants, indicating a failure to follow the facility’s infection prevention and control policy.
A resident with COPD and dementia, receiving scheduled nebulizer treatments, was found on multiple occasions to have a nebulizer mask stored on top of the machine rather than in a sanitary manner. A CNA and a nurse aide in training confirmed the mask’s placement, and an LPN reported that masks were routinely cleaned, dried, and then stored on top of the machine. The DON later acknowledged that masks should be washed, dried, and placed on a clean surface, and facility policy required oxygen and respiratory supplies to be stored in a plastic bag when not in use.
A resident with acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes was observed receiving oxygen at 4.5 L/min via nasal cannula without a corresponding physician order in the clinical record. The DON acknowledged that an order should have been in place before oxygen was initiated. Facility policy on supplemental oxygen via nasal cannula requires administration only under a physician or provider order, in alignment with 410 IAC 16.2-3.1-47(a)(6).
A resident was observed receiving O2 via nasal cannula on multiple occasions, but the chart had no current physician order for O2. The resident said she had been told after a recent hospitalization to use O2 for 30 days, but that time had passed and she was still using it because staff told her she needed it. The DON confirmed there was no current O2 order; the last order had already been discontinued.
Failure to provide and document respiratory care: A resident with a trach had no documented evidence of respiratory rate, depth, and quality being monitored each shift and as needed, despite oxygen orders and trach care needs. Other residents with CPAP, nebulizer, and oxygen therapy had respiratory equipment left out of required storage, missing CPAP settings and care details in orders and care plans, and MAR entries signed by nursing staff even when respiratory staff reportedly completed the equipment changes.
Unsecured Storage of Full Oxygen Cylinders on Nursing Unit
Penalty
Summary
Surveyors found that the facility failed to ensure safe storage of oxygen cylinders on the West 1 unit. At 9:03 a.m., four full oxygen cylinders were observed stored unsecured directly on the ground rather than in the designated secured cylinder storage rack, under a sign labeled "FULL CYLINDERS." Photographic evidence was obtained of this condition. At 9:18 a.m., the ADON confirmed that the four cylinders were full and acknowledged they should not be stored on the ground. Review of NFPA 99 (2021) 11.6.2.3(11) indicated that cylinders must be protected from damage and that freestanding cylinders must be properly chained or supported in a proper stand or cart. Later that day, the DON stated that oxygen cylinders should be stored in a secure rack and never directly on the ground, and acknowledged that unsecured cylinders on the floor were a safety risk. The Maintenance Director also confirmed that oxygen cylinders should be in a secure rack and never stored directly on the ground, stating that cylinders stored on the floor can tip over and cause damage. These observations and interviews demonstrated noncompliance with regulatory and NFPA standards for safe storage of oxygen cylinders.
Plan Of Correction
This plan of correction constitutes a written allegation of compliance for the deficiency cited. Submission of this plan of correction is not an admission that the deficiency exists or that one was cited correctly. This plan of correction is submitted to meet the requirements established by the State and Federal law. The four unsecured [R] cylinders on the West 1 unit were secured. The Nursing Department completed a baseline audit of [R] cylinder storage within the facility to ensure all [R] cylinders were secured and stored properly. Ongoing education will be completed with current facility staff regarding the facility's [R] storage policy and procedure; and will be completed during new hire and agency orientation to the facility by ADON/designee. Audits will be completed by the Director of Nursing/designee regarding adherence to the facility's [R] storage policy and procedure twice weekly x 4 weeks, then weekly x 4 weeks, then monthly x 4 months, or until continued substantial compliance has been met. Results of audits will be reported to the QAPI Committee on a monthly basis by the Director of Nursing/designee.
Improper Handling and Storage of Oxygen Nasal Cannula
Penalty
Summary
The deficiency involves the facility’s failure to follow its infection prevention and control program related to oxygen therapy equipment for one resident. The resident was an elderly female with dementia, COPD, depression, atrial fibrillation, hypertension, and hyperlipidemia, who had a comprehensive MDS indicating severe cognitive impairment and use of oxygen therapy. Her care plan identified risk for respiratory infections/distress related to COPD with an intervention to administer oxygen as ordered, and physician orders directed oxygen at 2–3 liters via nasal cannula to maintain oxygen saturation above 90% as needed for shortness of breath. On two separate observations, the resident’s nasal cannula was seen lying on the floor beside the bed instead of being stored in the bag on the oxygen concentrator when not in use, as required by facility practice. During interviews, an LVN, a CNA, the DON, and the Administrator all stated that oxygen nasal cannulas should be stored in a bag on the oxygen concentrator when not in use and that if a cannula is found on the floor it should be replaced. The CNA reported that she was unaware the tubing was on the floor until she entered the room to assist with the noon meal, then picked up the nasal cannula, wiped it with an incontinent wipe that did not contain disinfectant, and placed it back on the resident. She acknowledged she had been trained on oxygen tubing storage and should have replaced the cannula. The LVN, DON, and Administrator confirmed that incontinent wipes are for skin use and are not disinfectant wipes, and that staff had been trained on oxygen use and storage. The facility’s Infection Prevention and Control Program policy stated that the program is to help prevent the development and transmission of communicable diseases and infections, including instituting measures to avoid complications or dissemination, which was not followed in this instance.
Improper Storage of Nebulizer Mask and Respiratory Supplies
Penalty
Summary
Surveyors identified a deficiency in the sanitary storage of respiratory equipment for one resident receiving respiratory care. The resident was admitted with COPD and unspecified dementia and had care plan focuses for terminal prognosis due to COPD and shortness of breath, with interventions including administration of inhalers and nebulized medications as ordered. Physician orders included scheduled ipratropium-albuterol nebulizer treatments twice daily for COPD. During multiple observations in the resident’s shared room, the nebulizer mask was seen lying on top of the nebulizer machine rather than being stored in a sanitary manner. Staff interviews confirmed the observed storage practice. A CNA and a nurse aide in training each verified that the nebulizer mask was lying on top of the machine at the times of observation. An LPN stated that masks were cleaned after use, dried, and then stored on top of the machine, and acknowledged this could be an infection control issue. During a later observation, the LPN again confirmed the mask was on top of the machine. In an interview, the DON, with the Administrator present, stated the mask should be washed, dried, and placed on a clean surface and acknowledged it could be an infection control issue, and the facility’s written policy specified that oxygen and respiratory supplies were to be stored in a plastic bag when not in use.
Oxygen Administered Without Required Physician Order
Penalty
Summary
The facility failed to ensure physician orders were in place for oxygen administration for one resident receiving respiratory care. During an observation on 5/8/26 at 9:45 a.m., Resident 101 was noted to be receiving oxygen at 4.5 liters per minute via nasal cannula. Review of the resident’s clinical record later that day showed diagnoses including acute respiratory failure with hypoxia, pulmonary hypertension, and type 2 diabetes, but no physician’s order for the use of oxygen could be located at the time of review. In a subsequent interview on 5/12/26 at 8:14 a.m., the Director of Nursing stated that physician orders for oxygen should have been present in the record before oxygen was initiated. The facility’s undated policy titled “Supplemental Oxygen Using Nasal Cannula,” provided on 5/13/26, specified that supplemental oxygen may be administered via nasal cannula only at the order of a physician or provider, consistent with 410 IAC 16.2-3.1-47(a)(6). These observations, interviews, and record reviews demonstrate that oxygen was administered to Resident 101 without the required physician order, contrary to both facility policy and state regulatory requirements.
Missing Current Physician Order for Oxygen
Penalty
Summary
The facility failed to ensure a current physician's order was in place for a resident receiving oxygen via nasal cannula. Resident 3 was observed in her room on multiple occasions using oxygen from a humidifying oxygen delivery machine via nasal cannula. During interview, the resident stated she had been told after her last hospitalization to use oxygen for another 30 days, but that time had passed and she was still wearing the nasal cannula and receiving oxygen because staff told her she needed it; she also stated the nasal cannula bothered her and she did not want to wear it if it was not necessary. Review of the clinical record showed diagnoses including atrial fibrillation and anxiety, but no current oxygen order. The last oxygen order had a start date of 2/2/26 and a discontinued date of 2/23/26. The DON confirmed there was no current physician's order for oxygen for the resident.
Failure to Provide and Document Respiratory Care
Penalty
Summary
The facility failed to ensure appropriate respiratory care was provided and documented for residents with tracheostomy, oxygen, CPAP, and nebulizer needs. Facility policy required respiratory treatments and equipment care to be based on physician orders, care plans, and diagnoses, and required documentation of services provided, including date, time, and the name and title of the person providing care. The respiratory therapy job description stated respiratory staff assumed primary responsibility for respiratory care modalities, conducted therapeutic procedures, maintained resident records, and documented patient care services. Resident R3 had diagnoses including traumatic brain injury and respiratory failure and had a physician order for oxygen at 10 liters per minute continuously, titrated to maintain oxygen saturation above 90%. The resident’s MDS indicated tracheostomy care was required. During observation, R3 was receiving oxygen via face mask to the trach and pulse and oxygen saturation were being monitored. However, review of the clinical record failed to show evidence that the resident’s respiratory rate, depth, and quality were monitored and documented each shift and as needed. Staff interviews confirmed that nurses were responsible for reviewing care plans, monitoring respiratory status, and documenting changes, and that the facility failed to document and monitor R3’s respiratory rate, depth, and quality each shift and as needed. Resident R67 had obstructive sleep apnea, heart failure, and diabetes, with an order for CPAP at hour of sleep at home settings. The order did not include the setting or any care for the CPAP machine, and the care plan also did not include the CPAP settings or care needed for the machine. During observation, the resident’s CPAP mask was sitting on top of the bedside stand and was not stored in a bag as required. Resident R69 had emphysema and was ordered albuterol nebulizer treatments four times a day, but during observation the handheld nebulizer was sitting on top of the machine and not stored in a bag as required. Resident R11 and Resident R32 both had oxygen therapy orders requiring nasal cannula changes every two weeks, but the MAR showed changes documented by nursing staff while interviews confirmed respiratory staff actually performed the changes and that staff signed off even when they had not personally completed the task. The interviews also reflected confusion about who was responsible for the equipment changes and documentation.
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