Health inspection·February 15, 2025

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure emergency sized tracheostomy tubes for a resident (R1) who required tracheostomy care were available. This failure resulted in R1 experiencing acute respiratory distress and requiring an emergency hospitalization for acute respiratory failure. R1 had to be connected to mechanical ventilation for emergency respiratory support. The facility also failed to ensure licensed nurses were trained on how to change tracheostomy tubes and to dispose of expired tracheostomy inner cannulas. Residents Affected - Few This applies to 1 of 3 residents (R1) reviewed for respiratory care. The findings include: R1's EMR (Electronic Medical Record) showed R1 was admitted to the facility on [DATE] with multiple diagnoses including nontraumatic subarachnoid hemorrhage from an intracranial artery, ruptured aneurysm, acute respiratory failure with hypoxia, tracheostomy, obstructive sleep apnea, and hypertension. R1's EMR showed he was transferred to the hospital on [DATE] and was not readmitted . On [DATE] at 3:15 PM, V3 (Licensed Practical Nurse/LPN) said R1 was transferred to the hospital in the morning for acute respiratory distress. V3 said R1 was admitted with tracheostomy with a size 6 cuffed trach tube and was receiving supplement oxygen of 6 L (liters) via a trach collar with humified 28% of FiO2 (fraction of inspired oxygen). V3 was asked to assess R1's beside respiratory supplies. There was a box of size 6DIC inner disposable cannulas containing 10 cannulas with an expiration date of [DATE]. V3 said tracheostomy equipment should be checked and disposed of when expired. V3 was unable to locate any emergency tracheostomy exchange kits for R1. V3 said residents with tracheostomies required emergency tracheostomy exchange tube kits with an obturator (tracheostomy stoma insertion [NAME]) for emergency situations at the bedside. V3 said he was R1's nurse on [DATE] when his entire trach tube had decannulated (expelled out). V3 said he was unsuccessful when he attempted to reinsert a new trach tube for R1. V3 said R1 was then transferred to the hospital and returned the same day with a new trach tube. On [DATE] at 8:10 AM, V4 (Registered Nurse/RN) said she was R1's overnight nurse on [DATE]. V4 said that around 11:25 PM R1 was having low oxygen levels. V4 said she administered a nebulizer treatment and then attempted to suction R1 but was unsuccessful. V4 said R1 continued to have low oxygen levels. V4 said she then attempted to change R1's inner trach cannula but had resistance when she attempted to insert a new inner cannula. V4 said she was not trained in changing entire tracheostomy tubes. V4 said she then contacted R1's physician and received an order to transfer R1 to the hospital. V4 said the emergency paramedics arrived at 11:55 PM and requested for R1's emergency tracheostomy supplies. V4 said she provided V7 (Emergency Paramedic) with a size 7 tracheostomy exchange tube kit Page 1 of 3 145740 145740 02/15/2025 Aperion Care Elgin 134 North McLean Boulevard Elgin, IL 60121

F 0695 without an obturator because that was the only kit she had available at the bedside. V4 said R1 was then transferred to the hospital and admitted for acute hypoxemic respiratory failure. Level of Harm - Actual harm Residents Affected - Few On [DATE] at 8:35 AM, V7 (Emergency Paramedic) said that when the emergency response team arrived at the facility R1's oxygen levels were worsening. V7 said they attempted to ventilate and suction R1 but were also met with resistance. V7 said the protocol for when resistance is met with patients with tracheostomies is to change the entire trach tube. V7 said he asked V4 if she had attempted to change R1's trach tube, V4 responded no because she was not trained to change entire trach tubes. V7 said V4 then provided him with a new trach tube kit. V7 said the kit contained an uncuffed trach tube without an obturator. V7 said R1's trach tube was changed and then R1 was ventilated with a bag valve mask and transferred to the hospital. On [DATE] at 11:40 AM, V10 (Respiratory Therapist Manager) said her company provided the facility with as-needed external respiratory consulting services including tracheostomy care. V10 said residents with tracheostomies required specific emergency equipment at bedside including trach tube kits with the same type of trach tube and an obturator. V10 said the kits should include one of the same size and a downsized one. V10 said tracheotomy equipment should be checked routinely to ensure safe trach care is being provided. V10 continued to say licensed nurses could change trach tubes if there was a doctor's order and if they were trained appropriately. On [DATE] at 11:20 AM, V11 (Pulmonary Nurse Practitioner/NP) said she expected the facility staff to ensure all appropriate emergency tracheostomy equipment and supplies are maintained and kept at bedside according to the facility's policy to ensure safe tracheostomy care could be provided for residents with tracheostomies. On [DATE] at 1:30 PM, V2 (Director of Nursing/DON) said she confirmed that when R1 returned on [DATE] with a new trach tube, it was replaced with a size 4. V2 said the facility expects nursing staff to ensure that residents with a tracheostomy have the required emergency tracheostomy supplies at bedsides, including tracheostomy kits with a trach tube of the same size and a downsized tube, and an obturator. V2 said she also expects licensed nurses to follow the facility's tracheostomy policies to ensure they can respond safely to emergencies. V2 continued to say that she expects nurses to be able to change entire trach tubes monthly as ordered and during emergencies. R1's tracheostomy care plan initiated on [DATE] had multiple interventions including TUBE OUT PROCEDURES: Keep extra trach tube and obturator at bedside. R1's progress note dated [DATE] said O2 sat checked: 86%, Pulse: 75, RR: 20. Suctioning done but resistance noted. Nebulization done. At 11:25 PM, Resident is breathing with O2 sat: 86%, but still unable to advance suction catheter. Notified PCP and called 911. At 11:55 PM, EMS came and assessed the resident. At 12:05 AM, EMT notified the nurse/writer that they will try to change the trach in the facility. R1's Emergency Response report dated [DATE], said Nurse stated she tried to pass a suction tube down the patient's trach, but could not. Crew asked if the nurse had tried changing the trach and the nurse stated she was not authorized to change the trach .Crew asked nurse for a new trach tube and was given one. Crew attempted to ventilate with a bag valve mask and were met with resistance, not able to ventilate. Crew attempted to suction and met with resistance unable to suction. Patient's SpO2 reading was falling .Once tube was prepped, patient's tracheostomy was removed and replaced with new. Crew was now able to ventilate with a bag valve mask . 145740 Page 2 of 3 145740 02/15/2025 Aperion Care Elgin 134 North McLean Boulevard Elgin, IL 60121

F 0695 Level of Harm - Actual harm Residents Affected - Few R1's hospital note dated [DATE] said R1 was admitted for acute on chronic hypoxic respiratory failure. The note said EMS attempted to change the inner cannula, but they did not have the proper equipment; however after the clogged inner cannula was removed his SpO2 improved .Upon arrival to the ED he presented with stable and appropriate vitals but he quickly became hypotensive and hypoxic. His trach was connected to mechanical ventilation. R1's hospital note dated [DATE] said R1 was treated for a trach misplacement. The note said he came with a 6 french ET tube. However, there was some resistance on arrival, he had minimal blood. Here, a 4 french trach was placed and XR confirmed placement. R1's Order Summary Report dated [DATE] showed orders for Trach: Licensed nurse may re-insert trach tube, as needed for dislodgment and Trach: Change Trach tube every day shift every 1 month(s). The facility's admission Data Form: Tracheostomy Patient said the equipment needed included one same size trach and one downsized trach at the bedside at all times. The facility's Tracheostomy Care policy dated [DATE] did not indicate if licensed nurses were responsible for reinserting entire trach tubes nor did it provide instructions on how to perform the procedure. The policy states Emergency Care: If outer tube comes out, stay with resident and summon assistance. A rubber tipped hemostat maybe used to maintain opening. If necessary, suction the resident through the opening. Physician generally responsible for reinserting new tube. 145740 Page 3 of 3