Based on review of medical records and facility investigation documentation and interviews it was determined that the facility failed to ensure respiratory care was provided consistent with professional standards. This was found to be evident for one (Resident #40) out of four residents reviewed for respiratory care. This failure resulted in a determination on 5/31/24 at 9:45 AM of an Immediate Jeopardy for Resident #40. The facility implemented effective and thorough corrective measures following this incident. The facility's plan and action were verified during this survey, therefore this deficiency will be cited as past noncompliance. The date of correction was 5/24/24. The findings include: Review of Resident #40's medical record revealed the resident was admitted to the facility in February of 2024 with a history of stroke and dependence on mechanical ventilation due to respiratory failure. The resident had severe cognitive impairment and was non-verbal. On 5/20/24 the resident was observed resting in bed but did not respond to surveyor's greeting. Tubing connecting the ventilator to the tracheostomy tube was in place with no identified concerns at that time. A tracheostomy (also called a tracheotomy) is an opening surgically created through the neck into the trachea (windpipe) to allow air to fill the lungs. After creating the tracheostomy opening in the neck, surgeons insert a tube through it to provide an airway and remove secretions from the lungs. Residents with prolonged dependence on a ventilator for breathing will often have a tracheostomy. (www.hopkinsmedicine.org) Review of a 4/26/24 primary care physician (Staff #40) progress note revealed ventilator dependent respiratory failure -- stable on current vent settings. Not a candidate for vent weaning/decannulation at this time due to neurologic status remaining largely unchanged. Weaning refers to a process of gradually reducing the amount of ventilator support. Decannulation refers to the removal of the trach tube after it is no longer needed. Review of the progress notes revealed a note, dated 5/14/24 at 4:37 PM, by respiratory therapist (Staff #46) which stated: At approximately 1520 [3:20 PM] while documenting at the nursing station I heard a ventilatory alarming. After getting up and determining where the alarm sound was coming from I made my way to [Resident #40]'s room. When I arrived I witnessed that the patient was in the process of being transferred by two nursing assistants from [his/her] bed to a recliner chair via the hoyer lift and the patient had become disconnected from [his/her] ventilator. I stretched the ventilator to the patient as they were finishing the transfer to the chair and reconnected [Resident #40]. Immediately upon reconnection, the ventilator stopped alarming and the patient began to be ventilated again. The patient did not appear to be in distress at any time that I witnessed. Review of the progress notes revealed a note, dated 5/14/24 at 5:40 PM, by nurse (Staff #48) which documented: While transferring [Resident #40] from the bed to recliner, the nursing assistant disconnected the trach tube from the patient for the transfer. Vent alarm sounded and respiratory therapist responded to Pt.[patient] room and reconnected the airway to the ventilator. The disconnect time was approximately 2 minutes as per the vent alarm record. Clinical manager was notified. Review of the initial report from the facility for incident MD00205708 revealed that on 5/14/24 the Respiratory therapist reported he heard the vent alarm going off in the resident's room and immediately checked on the resident, when he entered the room, he saw the resident was disconnected from the ventilator while two GNA's [geriatric nursing assistants] were transferring the resident. The respiratory therapist immediately responded to the alarming ventilator and reconnected the ventilator to the resident. The respiratory therapist reported the resident was not in distress after the incident. The nurse assessed the resident after the incident and reported the resident was at baseline. The assigned nurse to this resident educated the GNA on proper ADL care with ventilators. Nursing management was notified, and they took both GNA's off the unit to the nursing manager's office and educated them. The nurse manager and two respiratory therapists were involved in the education. The ADON met with both GNA's after the education and educated them too. Review of a statement dated 5/15/24 and signed by GNA Staff #49 revealed that it was in regard to the incident that occurred on 5/14/24 while transferring a resident. The statement included: I was not aware that I am not supposed to transfer vent residents unless there is a respiratory staff to watch the process. Review of a statement dated 5/14/24 and signed by Staff #48 revealed Nurses aide stated to this nurse that she disconnected the Pt. [patient] vent tube from the patient to transfer [him/her] to the chair. On 5/31/24 at 7:46 AM, after a review of his signed statement, Staff #48 confirmed that the GNA referenced was GNA #49 and that the GNA had said that s/he had un-hooked the resident. On 5/30/24 at 2:30 PM, upon interview, GNA #49 reported she was an agency GNA and had been working at this facility for about 3 months. She confirmed the last time she worked with a resident on a ventilator was 5/14/24. She reported that if transferring a resident on a ventilator she would call staff from the respiratory therapy (RT) department. After review of her statement about the 5/14/24 incident GNA #49 confirmed that she did not call RT that time, and denied having been told prior to that incident that she needed to do so but confirmed that she had received education since then. GNA #49 denied that the tubing was disconnected and stated that it was stretched but it was attached. Review of the Competency: New Employee GNA/CNA staff form for GNA #49 revealed documentation to indicate Competency in regard to: Staff is able to verbalize the safe manner to provide care when working with ventilators and patients & residents with tracheostomies; and Staff is able to discern the difference between the various alarms on the ventilators and the appropriate response. The Respiratory Care Evaluator (RT supervisor Staff #47) signed this form on 2/15/24. On 5/31/24 at approximately 8:00 AM RT supervisor (Staff #47) was interviewed regarding the orientation process. Staff #47 reported that they would have covered that an RT needs to be in the room during a transfer. She also confirmed that there was an RT available on the unit 24 hours per day 7 days per week and they carried radios so they could always be reached. When asked what the Respiratory Care Evaluator Signature indicated, Staff #47 reported it meant they have been oriented. Review of a statement written by GNA (Staff #52) revealed s/he had precepted GNA #49. The statement included: I fully educated [him/her] on the transfer of [name of Resident #26], a ventilator patient. I neither disconnected the vent or tube feed from the patient. All tubes were in place during the entire transfer. Review of a statement dated 5/14/24 and signed by GNA (Staff #50) revealed that GNA (Staff #49) had requested assistance with providing care for Resident #40 and included the following: .At the verge of the transfer the vent was disconnected. I queried this action but my partner overrode my reservation and against my better judgment I went along. The resultant beeping attracted the prompt arrival of a respiratory therapist who quickly remediated the situation . Review of a statement signed by respiratory therapist (Staff #45) revealed that on 5/14/24 respiratory therapist (Staff #46) had alerted her to the incident and that she reported it to unit nurse manager (Staff #3). The statement indicates education was immediately provided to both GNAs involved. The statement includes the following: [GNA #50] stated that [s/he] told her not to disconnect the patient and her reply was it is only for a second. On 5/31/24 at 10:54 AM respiratory therapist (Staff #45) reviewed her written statement and confirmed it's accuracy. Staff #45 also reported that they do inform the GNAs not to disconnect residents as part of the orientation and that a respiratory therapist will help with moving or transporting a resident. Review of a statement dated 5/14/24 and signed by the unit nurse manager (Staff #3) revealed that upon learning of the event from respiratory therapists (Staff #46 and #45) at approximately 4:00 PM, the unit nurse manager immediately identified the two GNA's involved (Staff #49 and #50). The GNAs were then both educated by RT (Staff #45) on the importance of never disconnecting a resident from the ventilator as this is their 'life support' and could die from being disconnected. Further review of the unit nurse manager (Staff #3)'s statement revealed: [GNA #50] expressed remorse for following [GNA #49]'s lead and not being more forceful in stopping [GNA #49] from disconnecting the resident from the vent. On 5/31/24 at 9:21 AM during an interview with Staff #3 surveyor read this portion of the statement to Staff #3 and when asked if this was accurate, Staff #3 stated: absolutely correct. Staff #3 also confirmed that she was told by GNA #49 that she had disconnected the vent. On 5/31/24 at 7:13 AM GNA #50 reported he is employed by a staffing agency and had worked at this facility 3-4 days per week for the past year. GNA #50 reviewed his written statement and confirmed it's accuracy. GNA #50 reported the GNA who was the lead thought it was ok to transfer the resident without a respiratory therapist and during that process the tubing got extended and it got pulled off. During this interview, GNA #50 denied that the other GNA disconnected the vent but reported that it came off during the transfer and that the section of the statement about overrode my reservation was that he told the other GNA they should have a therapist in the room but the other GNA said no it would be easy. GNA #50 went on to report that he has received education regarding this issue and that he can no longer be assigned as the primary GNA for a resident with a vent. On 5/31/24 at 10:12 AM during an interview, the respiratory therapist (Staff #46) reiterated what was in the note he wrote on 5/14/24. Staff #46 also reported when he arrived the ventilator was 7 - 8 feet away from the resident, the tubing wasn't stretched out and it was sitting with the ventilator. Staff #46 also reported that staff were supposed to have an RT called in prior to a transfer and indicated that no one said anything about moving the resident to him prior to the incident. Further review of facility documentation revealed a statement that RT (Staff #45) verbally educated GNA #49 on the following: 1. Never disconnect a ventilator circuit or remove a resident from a ventilator during transfer or dressing or removing clothing. Not even for a moment. This also pertains to the trached residents who are on jet neb or room air. Always get a nurse or respiratory therapist for help. 2. Never stretch the ventilator circuit too far from the resident as this can cause a disconnection of the circuit from the resident's trach or it may cause decannulation from the resident's stoma [name of the hole the trach tube is inserted through]. Decannulated trachs may not be immediately visible, it can come out and lay on the chest under the trach dressing. Do not try to insert the trach. 3. Ventilators are needed to keep residents alive. This is how they breathe. They are on a ventilator because they cannot breathe on their own. If disconnected from a ventilator whether accidentally or intentionally, the resident could possibly pass away due to lack of oxygen. 4. There are always respiratory therapists on staff who are willing to help get residents out of bed to handle the ventilators and tubing. Please get them to help with any ventilator residents, even if it is for care while the resident is in bed. This document included the statement I agree that I have been educated by Respiratory Therapist on the topics stated above on May 14, 2024 witnessed by [RT Staff #46 and Unit Nurse Manager Staff #3]. The form was signed by GNA #49 and by Staff #3 on 5/14/24. On 5/30/24 review of the completed facility-reported incident follow-up investigation report regarding the 5/14/24 incident revealed the following statement: Summary of the interviews include that the GNA disconnected the resident from the ventilator to transfer the resident. This was observed by another GNA in the room. Further review of the follow-up investigation report revealed the following corrective action was taken: Agency GNAs are not to be assigned to ventilator-dependent residents and all GNAs receiving education by the respiratory therapist regarding proper care of ventilator/tracheostomy residents. Further review of the facility documentation revealed an Education Sign-in Sheet for GNA Respiratory Education for May 20 - 24, 2024 that included 28 GNA signatures. Review of the list of GNAs who work at the facility revealed 25 employees and 5 agency GNAs. On 5/30/24 at 4:10 PM the NHA confirmed education was completed by May 24, except for one GNA who was on leave and then provided documentation that GNA was educated on 5/28 when she returned to work. NHA also indicated one of the 5 agency GNAs has not worked at the facility since the incident but has been made aware will need to be educated prior to working again. Review of the GNA Respiratory Education sheet revealed the following were covered in the training: 1. Never disconnect the ventilator circuit or remove a patient from the ventilator during transfer, or to dress/remove clothing from a patient. Always ask the respiratory therapist for assistance. 2. Vent tubing placement- Make sure that vent tubing moves freely to prevent pulling of the trach while performing patient care. 3. Decannulation - If the trach becomes dislodged during patient care, call for respiratory to re-insert the trach back into the stoma. Do NOT attempt to re-insert the trach yourself. 4. Do NOT silence the alarm on the ventilator by hitting the Silence Alarm button. 5. Suction regulators should not be turned on FULL suction while performing mouth care. Regulators should be turned no higher than 150 mmHg. Regulators should also be turned back down when finished. On 5/30/24 based on review of facility documentation and interview with several GNAs surveyor confirmed the facility completed the GNA training. On 5/31/24 at 8:00 AM the NHA confirmed that they will be following up in Quality Assurance regarding this issue and indicated that they address all their facility-reported incidents in QA. NHA also reported that they will be reviewing their training materials. Review of GNA #49's employee file revealed a Nursing Service Orientation Topic Validation 2023 form that was noted to be blank. On 5/31/24 at 9:28 AM the NHA reported that this form had not been implemented prior to the event on 5/14/24. This form included a section for Respiratory Training/Ventilator Equipment: Types of Tracheostomies & Tracheostomy Care; Ventilator Functionality; T-piece functionality - Aides Should Not Disconnect to Move Patient; Turning and Positioning Safety for Patient with Tracheostomy; Trach Collar, Respiratory Training/Ventilator Equipment and Ventilator Alarm Recognition & Safety: Disconnections etc. On 5/31/24 at 9:30 AM the NHA confirmed that moving forward they will be utilizing the Nursing Service Orientation Topic Validation form and will also be including the training that was completed with all of the GNAs post incident for new hires.