CLASS AA CITATION -- PATIENT CARE
42 CFR §483.25 (k) Quality of Care. Special Needs.
The facility must ensure that residents receive proper treatment and care for the following special serv'ices:
(4) Tracheostomy care;
(5) Tracheal suctioning; and
(6) Respiratory care.
42 CFR §483.25 Quality of Care. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.
The facility failed to ensure that Resident 1, who had a tracheostomy tube [surgical opening in the neck (windpipe) to place a tube to enable breathing], received proper respiratory and tracheostomy care and services to prevent repeated self-decannulation (pulling out of the tube), including but not limited to, failure to:
As a result, Resident 1 pulled out (decannulated) the tracheostomy tube three times; the third event resulted in respiratory distress that led to cardiopulmonary arrest (stoppage of the heart-lung function) and death.
On November 4, 2013, the Department received an Entity Self-Reported Incident (CA000375819) that alleged Resident 1 died on September 22, 2013, due to untreated tuberculosis (infectious disease that usually affects the lungs). On December 13, 2013, an investigation was initiated.
A review of the admission record indicated Resident 1 was admitted to the skilled nursing facility (SNF) on August 28, 2013, with diagnoses that included chronic respiratory failure, tracheostomy tube, gastrostomy tube (GT, insertion of a feeding tube into the stomach through surgical opening), coronary atherosclerosis (hardening of the arteries that supply blood to the heart), and dementia (disease impairing memory and intellectual functioning).
A review of the admission physician's orders dated August 28, 2013, indicated the following:
According to the physician's Progress Notes dated September 21, 2013, Resident 1 's diagnoses also included chronic obstructive pulmonary disease [COPD- a chronic inflammatory lung disease that causes obstructed airflow from the lungs] and anemia
(red blood cell count is less than normal and the cells in the body do not get enough oxygen).
A review of an Admission/Working Care Plan dated August 28, 2013, indicated Resident 1 had a problem related to altered gas exchange requiring use of a tracheostomy tube. The goal of the care plan indicated the airway would remain patent (open) for 30 days. The interventions included to assess respiratory status every shift and as needed; and document abnormal findings and notify the physician. The plan of care did not include interventions to securely anchor the tracheostomy tube to prevent dislodgement accidentally and/or by the resident.
According to the Subacute Daily documentation dated September 1, 2013, at 9:40 a.m., Resident 1 was seen and examined by his physician. New orders were written by the physician for tracheostomy culture and sensitivity and for a chest x-ray.
A review of the chest x-ray result dated September 3, 2013, indicated Resident 1 had widespread bilateral (both) lung opacities (difficult to see through) present more in the left lung base. This diagnostic result also indicated that this may be due to bilateral pneumonia (Jung infection), most severe in the left lung.
According to the Minimum Data Set [MOS- a comprehensive assessment and care screening tool], dated September 4, 2013, Resident 1 rarely made himself understood and rarely was able to understand others. The MOS indicted Resident 1 was totally dependent on the facility staff for all his care needs.
A review of the Resident 1 's sputum laboratory test results dated September 6, 2013, indicated it was positive for Methicillin/Oxacillin (antibiotics) resistant organism (bacteria resistive to antibiotic treatment). A second diagnostic laboratory culture test the same date, indicated the resident's sputum was positive for mycobacterium tuberculosis complex (bacterial infection).
A review of laboratory (lab} blood test results for Resident 1 indicated the resident's oxygen supply was compromised, and the need for uninterrupted oxygen supply as ordered by the physician was vital, as follows:
A review of Resident 1 's Respiratory Therapy Notes indicted the following:
A review of a plan of care dated September 10, 2013, indicated Resident 1 was at risk for ineffective airway exchange/chest congestion, and shortness of breath secondary to aspiration and respiratory condition secondary to COPD, GT feeding, respiratory failure, tracheostomy tube (trach), and pneumonia. The goal of the care plan was to have effective airway exchange. The interventions on the plan of care included to monitor the resident's breathing pattern, monitor for presence of chest congestion or increased respiratory distress, and document changes from baseline (normal for this resident), and notify the physician; to monitor for increased secretions; and to monitor oxygen saturation [a relative measure of the amount of oxygen that is dissolved or carried in the body]
An oxygen saturation in a range of 96% to 100% is generally considered normal.
Anything below 90% could quickly lead to life-threatening complications. The margin between "healthy" saturation levels (95-98%) and respiratory failure (usually 85-90%) is narrow. Kathy Lawrence, MSN, RNBC and Sue Simpson Johnson, BS, RRT Measuring Oxygen Saturation.
The plan of care dated September 10, 2013, also did not include interventions to
(1) securely anchor the tracheostomy tube to prevent Resident 1 from pulling out the tube, and (2) emergency interventions to be implemented in the event the tube is pulled out.
According to the Respiratory Therapy Notes, Resident 1 had pulled out his tracheostomy tube on three occasions as follows:
Following the two incidents of self-decannulation on September 17, and September 18,
2013, the interdisciplinary team (IDT), that included the physician, the respiratory therapist and the licensed nursing staff, did not update Resident 1 's plan of care to include interventions useful to prevent self-decannulation such as to properly tie and anchor the tracheostomy tube to assure the resident would not be able to remove the tube.
3. On September 22, 2013, at 11 :30 p.m., a review of the Subacute Daily Charting indicated Resident 1 was found with his tracheostomy tube pulled out. The tracheostomy tube was re-inserted, and the resident was noted to be in respiratory distress. Resident 1 was given emergency oxygen via ambu-bag (a device used to provide assisted ventilation to people who are either not breathing or are having trouble breathing) with 100 percent oxygen. Cardiopulmonary-resuscitation [CPR- a lifesaving technique to provide physical breathing and pumping of the heart] was initiated due to Resident 1 's lack of a pulse.
On September 22, 2013, at 11 :35 p.m., paramedics were called. At 11 :40 p.m., paramedics arrived and took over the care. At 11 :48 p.m., Resident 1 was pronounced dead.
The physician's order to treat Resident 1 's medical conditions, such as chronic respiratory failure and pneumonia, by administering oxygen and medications, was disrupted each time Resident 1 self-decannulated, causing disruption in his breathing which led to oxygen deprivation.
On September 18, 2015, at 12:30 p.m., during an interview the Respiratory Therapy Director (RTD) stated that there was no way to tell when a resident is going to pull out the trach tube. According to RTD, there was no alarm to alert the staff when Resident 1 pulled out his tracheostomy tube. RTD stated on September 22, 2013, Resident 1 was observed at 11 :15 p.m., before the trach tube was pulled out. At 11 :30 p.m., the resident was observed with the tracheostomy tube pulled out. The RTD stated he would not question this because, "It was not like a two hour gap between observations, it was only 15 minutes." According to the RTD, this meant that the respiratory therapist (RT) was making his rounds. The RTD confirmed that Resident 1 's plan of care had not been updated since the resident first pulled out his trach tube, with alternate interventions to prevent self-decannulation. The RTD stated this was the responsibility of the RTs and nursing licensed staff.
On September 18, 2015, at 1 :25 p.m., during an interview, RT 2 stated residents with tracheostomy tubes are supposed to be monitored by visual checks by the RTs, nursing, and certified nursing assistants. RT 2 stated in the past, it was the facility's practice to monitor a resident with a history of self-decannulation by sitting in front of the resident and continuously monitoring a resident (one-on-one) this way. RT 2, when asked, did not know if this was the facility's protocol or if individual staff members would take it upon themselves to monitor a resident in this manner.
On September 18, 2015 at 2:30 p.m., during another interview, the RTD stated Resident 1 's care plan had not been updated and there was no protocol put in place. During the interview, RTD stated someone should have been assigned to Resident 1 for one-to-one monitoring as soon as possible after the first self-decannulation incident. The RTD stated this incident with Resident 1 could have been avoided.
On September 18, 2015, at 2:55 p.m., the Director of Nursing (DON) stated that it was a standard practice to have a sitter assigned (one-to-one monitoring) to residents who self-decannulate, and an assessment should be done to determine if there is an underlying reason why the resident manifests the behavior of pulling out the tracheostomy tube. The DON stated one-to-one monitoring should have been assigned to Resident 1, and the plan of care should have been updated and individualized to include one-to-one monitoring activities.
According to the facility's revised policy dated January 1, 2012, titled "General Documentation Policy," the care plans shall be reviewed and revised at a minimum of quarterly or more often as the resident's condition warrants and in accordance with State and Federal Regulations.
The facility's undated policies and procedures regarding "Tracheostomy Care" provided by the DON did not address precautions on how to prevent residents from pulling out a tracheostomy tube.
According to the Certificate of Death, Resident 1 's immediate causes of death included: (A) Cardiac Arrest (sudden stop in effective blood circulation due to the failure of the heart to contract effectively); and (B) Myocardial Infarction (heart attack).
The facility failed to ensure that Resident 1, who had a tracheostomy tube, received proper respiratory and tracheostomy care and services to prevent repeated
self-decannulation, including but not limited to, failure to:
As a result, Resident 1 pulled out the tracheostomy tube three times; the third event resulted in respiratory distress that led to cardiopulmonary arrest and death.
The above violation presented either imminent danger that death or serious harm would result or a substantial probability that death or serious physical harm would result, and was a direct proximate cause of Resident 1 's death.