**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility did not ensure that a resident (R) received tracheal/stoma (soft tissue opening in tracheal airway) suctioning of respiratory secretions to maintain adequate respiratory care in accordance with professional standards of practice for 1 of 1 resident (R17) with a tracheostomy/stoma. R17 has tracheostomy from a laryngectomy. R17 has a build-up of secretions and a history of mucous plugs in R17's airway, which have required emergency room (ER) visits on 7 occasions from 1/13/25 - 4/28/25. On five of these ER visits, suctioning was required to remove mucous plugs and to receive respiratory care. Facility failure to ensure staff provided appropriate tracheal/stoma care including suctioning, created a finding of immediate jeopardy that began on 01/13/2025. Surveyor notified Nursing Home Administrator (NHA) A and Director of Nursing (DON) B of the immediate jeopardy on 05/22/2025 at 3:15 PM. The immediate jeopardy was removed on 05/22/25; however, the deficient practice continues at a scope/severity level of D (potential for more than minimal harm/isolated) as the facility continues to implement their interventions for residents requiring respiratory care services. Findings include: Facility policy titled, Tracheobronchial Suctioning, reviewed on 07/06/2022 states in part: Tracheobronchial suctioning is an effective way to maintain a clear airway and to aid in the removal of secretions for patients who are unable to clear their secretions when coughing. Indications - 1) Accumulation of secretions in the airway 2) Obstruction of airway due to secretions . Policy Explanation and Compliance Guidelines: 1). Review physician order . 9). Turn on suction . Facility policy titled, Tracheostomy Care, reviewed on 07/06/2022 states in part: Indicates care for cleaning and the buildup of mucus . 1) review physicians orders . 6) Suction the trach as necessary . Facility Assessment indicates: B. Services provided .Therapy . Respiratory . and Other special care needs . tracheostomy care. According to Tracheal Education. (2019, May 30). Tracheal Suctioning. https://tracheostomyeducation.com/suctioning/, .Suctioning is an important part of care for both the individual with a tracheostomy as well as a laryngectomy. Tracheal suctioning is performed to remove secretions from the trach tube and airway in order to maintain a patent airway and avoid tracheostomy tube blockages. Suctioning is a lifesaving procedure requiring timely and precise methodology. If done appropriately with caution, it decreases the risk of infection, pooling of secretions, and prolonged hypoxia . According to Tracheostomy Education. (2024, February 6). What is a Laryngectomy? https://tracheostomyeducation.com/blog/laryngectomy/ states, in part: .The patient does not breathe through the upper airway. Instead, breathing occurs through the stoma. Breathing, speech, and swallowing are significantly changed after the procedure. Since the stoma is the only passageway for breathing, it is important to maintain the airway and suction the trachea through the stoma as needed, using a sterile technique. It is also important to clean the stoma, as crusting of the secretions may develop that can block or occlude the stoma . R17 was admitted to the facility on [DATE] with diagnoses including laryngeal cancer, absence of larynx (laryngectomy), hemiplegia and hemiparesis following cerebral infarction affecting R17's right dominant side, chronic obstructive pulmonary disease (COPD), weakness, anxiety disorder, and tracheostomy. R17's Minimum Data Set (MDS) assessment dated [DATE] documents R17 has a Brief Interview for Mental Status (BIMS) score of 13/15, which indicates intact cognition. R17 requires extensive assistance to total dependence on staff for activities of daily living (ADLs). R17's physician orders for suctioning as needed (PRN) started on 05/11/2023 and were discontinued on 03/26/2025 with no documentation as to why this occurred. R17 has an order for oxygen (O2) at 2L/minute (min) via nasal cannula to keep oxygen saturation levels at or above 88% for respiratory distress as needed. R17's care plan indicates R17 is resistive/noncompliant with treatments/care of respiratory/stoma/tracheostomy related to coping with disease process and life situation. Will verbalize understanding of consequences of refusal/noncompliance. R17 will comply with care routine/medical regimen. If R17 resists care, leave (if safe to do so) and return later, inform R17 of ADL that is required ahead of time and give two options of times to be done. Give R17 a choice and allow for flexibility in routine. R17's care plan indicates R17 is at risk for change in mental status or acute confusional state as evidenced by multiple ER visits, history of respiratory infections secondary to noncompliance with tracheostomy/stoma care. R17 has difficulty communicating as evidenced by tracheostomy due to laryngeal cancer. R17's care plan indicates R17 is at risk for respiratory impairment related to COPD, tracheostomy. Per resident requires upright position due to shortness of breath (SOB) while lying flat . Interventions include maintain patent airway, will have no acute respiratory distress, administer medications as ordered, administer oxygen per providers orders, ensure head of the bed (HOB) is elevated at least 45 degrees and/or use of 2 or more pillows to prop resident up to prevent feelings of SOB, educate resident/representative on diagnosis, treatment and risks for complications, encourage deep breathing exercises, evaluate lung sounds and vital signs (VS) as needed. Care plan states to report abnormalities to physician, obtain pulse oximetry (pO2), and report abnormal findings. Position R17 as upright as possible during and after meals, provide assistance with ADLs to conserve energy, report signs of infection or edema, suction per physician orders, therapy evaluation and treat as ordered, and trach care per protocol. Surveyor noted multiple emergency room visits in R17's medical record. Surveyor reviewed Emergency Medical Service (EMS) reports regarding R17. On 01/13/25 at 11:03 AM, EMS was called to facility. EMS documentation states R17 was breathing rapidly. A non-rebreather mask was applied with oxygen at 8 liters (L)/minute, EMS documented R17's vitals at 11:15 AM, blood pressure (B/P) 166/82, pulse (P) 88, respirations (R) 44, and O2 saturation 87%. On 1/13/25, ER documentation states R17 presented with some shortness of breath (SOB). O2 sat improved with blow-by oxygen to 92% and B/P improved to 130/76. Documentation states facility does not have a respiratory therapist (RT) and is unable to perform deep suctioning. Following suctioning by cardiopulmonary a large mucous plug was removed. Documentation states R17 said if facility was able to provide the suctioning R17 would not have to come to the ER. On 1/17/25 at 2:21 AM, EMS called to facility. Documentation states R17 in obvious distress with difficulty breathing. EMS personnel suctioned R17 and mucous plug removed from tracheostomy. R17's vital signs per EMS at 2:39 AM, B/P 145/87, P 97, R 20, O2 sat 87%. R17's vital signs at 2:43AM, B/P 138/85, P 88, R 18, and O2 sat 92%. On 1/17/25, ER documentation states O2 sat at 2:51 AM was improving at 90%. Respiratory Therapy (RT) was called and R17 was suctioned which did result in removal of some secretions. A saline nebulizer (neb) was then given, and another suction attempt resulted in some more sputum. Hospital record on 1/17/25 at 3:07 AM, Patient Updates, Patient reports that when his trach was clogged, he felt like he was going to die. On 1/23/25, R17 was seen by an Ear, Nose, and Throat (ENT) specialist at the clinic due to having mucous plugging with tracheostomy. ENT documentation states R17 is experiencing recurrent mucous plugging, which is unfortunately a common complication of laryngectomy. R17 needs to be treated with very diligent humidification including use of heat moisture exchanger (HME). Additionally, R17 should utilize irrigation and suctioning as needed. Should be seen in the emergency room if needed. On 1/23/25, facility documentation states R17 returned from appointment with ENT. Documentation states R17 had some dried green secretions in proximal trachea. ENT debrided those, distally mild amount, white bronchial secretion. Facility documentation worded ENT note stating if needs suctioning will need to be seen in the ER. This differs from quoted documentation as stated above. On 1/23/25 at 8:11 PM, facility progress note states R17 kept heated humidity on for about half of the shift. R17 wanted it off the rest of the time. No documentation provided by facility showing education was provided to R17 emphasizing the importance of humidification with a tracheostomy. On 1/31/25, ER documentation states R17 arrived by ambulance with SOB. Documentation stated R17 not in acute distress. Stoma looks good. R17's vital signs B/P 122/58, P 64, R 26, O2 sat 92, and T 97.7. Note states tracheostomy mucous plug was relatively easily removed. Mucous plug removed with assisted cough by R17 and superficial suctioning. ER documentation states, The care provided in ER is clearly within the nursing home Registered Nurse (RN) scope of practice. There is no reason for hospitalization. R17's needs are ongoing regular tracheostomy care to prevent recurrence or a situation that is worse. On 1/31/25 at 3:20 PM, facility documentation states facility spoke with hospital and R17's plan of care will be for facility to suction at bedside the surface of trach for discomfort with mucous. There will be new order for albuterol and hypertonic saline for nebulization to help R17 cough and release mucous plugs. Of note, there is no evidence education was provided to R17 on ways to prevent mucous plugs, or any new intervention implemented to assist with needed respiratory care. On 3/29/25, R17 was transferred from the facility to the ED for fever and decreasing oxygen saturations. VS at 2:04 AM were as follows; temperature (Temp) 101.3 F, Pulse (P) 82, Respirations (R) 35, BP 130.60, SpO2 95% on 5l/min of oxygen. Records indicate: Hypoxia, increased oxygen needs, suspected pneumonia. ED course indicated, Mucus plug, inadequate humidification, infection, poor trach care. R17 was admitted to the hospital, was followed by RT, respiratory panel was positive for Corynebacterium propinquum (bacteria in the oral pharyngeal). R17 was diagnosed with pneumonia, treated with vancomycin and sent back to the facility on doxycycline (an antibiotic). R17 was discharged back to the facility from the hospital on 4/2/25. Findings at discharge include supplemental oxygen requirement which is not his baseline. On 04/16/25 at 10:41 AM, facility documentation states R17 displayed agitation while taking nebulizer off. R17 had expressions of disgust and irritability. On 4/19/25, ER records indicate R17 was taken to ER by ambulance with difficulty breathing. Review of ER notes indicate R17 stated it's been a while since they suctioned him at the nursing home and his breathing got worse yesterday and today. R17 felt and looked improved after neb with RT, who knows him well. ER discharge note indicated that neb was given, and suctioning was not done at this time. On 04/21/25 at 10:03 AM, EMS at facility. Documentation states R17 felt like something stuck in trach. EMS documentation states RN at facility stated suctioning was performed on R17. EMS performed visual inspection and trach appeared clear. EMS performed vital signs on R17. At 10:08 AM, B/P 159/99, P 70, R 16, O2 sat 97%. At 10:16 AM, B/P 164/107, P 70, R 16, O2 sat 96%. Surveyor reviewed facility documentation and R17's medical records did not show RN performed suctioning on R17 prior to EMS arrival. Facility did not implement any new interventions for R17 after this ER visit. On 04/21/25 at 10:21 AM, ER documentation states R17's prearrival vital signs: B/P 159/99, P 70, R 20, O2 sat 98%. ER documentation states R17's chief complaint is trach problems, care. R17 presents from nursing home after having trach suctioned. The nursing home reports R17 still has phlegm stuck in the trach and sent R17 to ER to be evaluated. In ER at 10:26 AM, R17's vital signs: B/P 163/67, P 67, R 22, O2 sat 94%. R17 not in acute distress. Nebulizer treatment given and suctioning performed by RT and large mucous plug removed. ER documentation states diagnoses of poor trach care, mucous plug, and inadequate humidification. On 04/21/25 at 12:08 PM, facility documentation states R17 was transported back to facility. Facility RN called ER and received report that R17 was suctioned with no results. R17 received a duo neb treatment and no new orders given. Of note, facility note does not align with ER visit note; a mucous plug was removed. Of note, the facility documentation on 4/21/25 does not align with the ER note that documents a large mucous plug was removed. On 04/24/25, Nurse Practitioner (NP) E saw R17 at facility. NP E's documentation states nursing home is unable to deep suction R17 due to regulations, so R17 requests ER transport. NP E documents NP E discussed R17's case with hospital RT and agreed with RT ER transport is not likely needed. NP E documentation states, We are working with the nursing home and RT/EMTs for a better plan of care. NP E documentation states R17 has a history of non-compliance with trach filter and nebulizer treatments. On 04/28/25 at 4:07 PM, EMS called to facility and EMS suctioned 10 ml phlegm from R17's trach. EMS documentation states R17's vital signs: B/P 139/74, P 78, R 14, O2 sat 96%. At 4:36 PM, R17's vital signs: B/P 129/70, P 80, R 18, O2 sat 94%. On 04/28/25 at 4:38 PM, ER documentation states R17 has cough, SOB, and wheezing. R17's vital signs: B/P 134/67, P 81, R24, temp 98.9, and O2 sat 92%. ER documentation states breath sounds reduced. Chest x-ray results were clear. Electrocardiogram (EKG) results normal sinus rhythm. ER report stated, He is able to do basic suctioning but not deep suctioning at the nursing home (NH) and the nurses are not trained to do this nor do they have the equipment. He comes to the ED frequently requesting deep suctioning. He has been having increased SOB the past few weeks and has come over for suctioning. Discharge instructions - attempt suctioning at NH as well as possible when he can. Return if there is severe blockage. R17 is unable to suction trach per self. The facility had no evidence that education was given to staff on providing suctioning to R17 after this ER visit. NP E's progress note dated 05/23/25 states on 05/22/25 NP E spoke with ENT and NP's documentation states R17's case was discussed. ENT recommends having suction available for patients with a tracheostomy but makes exception for R17. Documentation states ENT states R17 is in a skilled facility with nursing and care staff 24/7 and R17 is able to produce a productive cough to help control secretions. R17 wears the HME, is alert and oriented, and able to make needs known. Documentation states Yankauer suctioning would not prevent plugs from forming and would not decrease need for emergency room visits. R17 states he is unable to clear mucous plugs. **Note-this progress note and conversation between NP E and ENT took place after the facility was made aware by surveyors of the respiratory/trach/stoma care and suctioning concerns. On 05/20/2025, Surveyor observed R17 had nebulizer equipment in room. R17 did not have suctioning equipment in room or at bedside. Surveyor observed facility airway suctioning equipment is kept on a crash cart in the facility medication room. On 5/22/25 at 10:21 AM, Surveyor interviewed DON B and NHA A, who reported the facility does not do deep suctioning. Later, DON B reported deep suctioning is anything beyond the opening of the trach. On 5/22/25 at 10:35 AM, Surveyor interviewed NP E, who reported, I think we had an order for Yankauer (shallow oral cavity) suctioning. NP E reported that R17 wants to go to the ER. He likes the attention. His nebs are effective. I have a direct line to the ER. NP E reported R17 doesn't need deep suctioning. NP E reported RT from the hospital has told NP E this. Surveyor asked NP E how facility staff determine when to send R17 to ER. NP E stated, They call me. I have them get vital signs, cleanse trach site, administer nebs and humidified air. I have him attempt cough and deep breath and then send him to the ER if he wants to go. He is his own person, if he wants to go to the ER, we have to honor that. On 5/22/25 at 10:55 AM, Surveyor interviewed DON B who reported the facility would provide oral cavity suctioning if R17 needed it. DON B stated, We are not doing any deep suctioning. DON reported the facility could suction around the outside of the stoma but that's not what he needs. He will tell us when he has a mucus plug. DON B reported the facility does not consider suctioning in the trach part of trach care. Surveyor asked DON B what was considered trach care. DON B replied, Cleansing and caring for it. Surveyor asked DON B how would a new nurse know what to do if R17 experiences respiratory issues. Surveyor asked if a plan of care is in place which lists steps to take when R17 has difficulty breathing. DON B reported the facility would train on trach care, site care, and oral suctioning. DON B stated, We don't have a respiratory therapist. DON B further stated, We took [R17] because [R17] was supposed to be short term. We will never take another trach patient. DON B reported they have not done any type of suctioning to R17. Facility did not have any suctioning orders from March 26, 2025, until suctioning PRN order signed by physician on 04/03/25. Surveyor requested any documentation of suctioning provided to R17 since his admission. No documentation was provided. On 5/22/25 at 11:10 AM, Surveyor interviewed R17. Surveyor asked if R17 feels nervous when he cannot breathe well and needs to be suctioned. R17 nodded his head up and down indicating yes. R17 does not recall if the facility has ever tried to suction him. Surveyor asked R17 if he requests to go to the ER. R17 replied he has asked to go sometimes and sometimes the facility has just sent him to the ER. R17's replies were with use of a voice amplifying device. Surveyor asked if R17 is concerned or has anxiety when he must wait for the ambulance to go to the ER to be suctioned instead of the facility doing the suctioning. R17 nodded his head up and down indicating yes. When Surveyor asked if R17 ever suctions himself, R17 shook his head side to side indicating no and opened his eyes wide. Surveyor asked if R17 would allow facility to perform trach/stoma suctioning rather than going to the ER. R17 used his microphone and stated, If they knew what they were doing. When Surveyor asked if R17 can cough and clear the secretions himself, R17 shook his head side to side indicating no. Surveyor interviewed facility staff and found staff were not aware to suction R17's trach/stoma, nor did they provide suctioning to R17. There was no suctioning equipment at R17's bedside for emergency suctioning that could be needed. On 5/22/25 at 1:00 PM, Surveyor interviewed Registered Nurse (RN) C about respiratory trach/stoma training. RN C reported RN C was trained on managing R17's trach/stoma and to never stick anything in the stoma. RN C stated, I never had specific cannula care training. Surveyor asked RN C how RN C would know if R17 was having problems with R17's trach/stoma. RN C reported that R17 will tell them. On 5/22/25 at 1:02 PM, Surveyor interviewed Licensed Practical Nurse (LPN) D, who reported LPN D would assess for secretions, call the on-call provider, and send R17 to the ER. The facility's failure to provide appropriate tracheal/stoma care including suctioning of respiratory secretions in accordance with professional standards of practice created a reasonable likelihood for serious harm, which led to a finding of Immediate Jeopardy. The facility removed the immediate jeopardy on 05/22/25; however, the deficient practice continues at a scope/severity level of D as the facility continues to implement the following action plan: -R17 had a trach/stoma care and lung assessment completed by DON B or designee on 05/22/25. -Emergency suctioning equipment placed at R17's bedside. -On 05/22/25, DON B contacted R17's primary care provider (PCP) and obtained orders for trach/stoma suctioning as needed. -Starting on 05/22/25 facility licensed nursing staff reeducated on tracheostomy stoma care including suctioning of tracheostomy by DON B or designee prior to the start of each licensed nursing staff's scheduled shift. -On 05/22/25, AD HOC Quality Assurance and Performance Improvement (QAPI) meeting held.