IDPH has cited and fined Aliya of Palos Park when a resident died after the facility failed to assure that the airway with a tracheostomy was free of obstruction during CPR attempts.
The resident in question was suited with a tracheostomy and various diagnoses including Acute Bronchitis, Dysphagia, Chronic Respiratory Failure, and Vascular Dementia. When the resident developed respiratory distress, staff members were unable to locate a spare inner trach tube to provide oxygen and clear the resident’s airway.
A Licensed Practical Nurse (LPN), noticed the resident’s distress and started chest compressions, stating, “I started chest compressions and the resident had a faint pulse.” A registered Nurse (RN), attempted to suction the resident and reported, “I suctioned the resident and she was clear.” However, the RN later admitted, “no one had trained me at the facility with trach care.”
During the code, paramedics arrived and asked for a new inner cannula for the resident, but the staff was unable to find one. The resident’s family member, who had recently arrived, stepped in to assist. The family member said, “I removed my mother’s inner cannula and it was clogged with mucus. You could not see through the inner cannula that had been removed.”
Paramedic records from the incident document, “Crew tried to bag patient and met with great resistance. Crew asked nurses to change the port tube for the trach, and they had to find someone to do it. Crew unable to vent patient appropriately due to how clogged the tube was. Crew also notes, the facility staff was “trying to bag without the oxygen cylinder on.”
The resident was transported to the local emergency room. Hospital records noted, “patient has a trach that per EMS ‘was so clogged we were pulling out chunks.” Despite efforts, the resident was pronounced deceased.
The care facility had several shortcomings that contributed to the incident involving the resident:
1. Lack of staff training: A Registered Nurse admitted that no one had trained her on trach care at the facility. This lack of proper training likely contributed to the staff’s inability to handle the emergency situation effectively.
2. Inadequate emergency equipment: During the code, staff could not locate a spare inner cannula for the resident’s tracheostomy tube. This suggests that the facility did not have adequate emergency equipment readily available.
3. Insufficient documentation: The facility’s records did not document the removal of the resident’s trach tube to check for clogs during the emergency, despite the facility’s Tracheostomy Care Policy stating that the inner cannula should be removed and a new one inserted.
4. Incomplete facility assessment: The facility’s assessment tool did not identify Respiratory Therapy Services, and the number of residents with tracheostomy care was listed as zero. This suggests that the facility may not have been properly prepared to care for residents with tracheostomies.
5. Staff not current with CPR certification: Several staff members did not have current CPR cards on file. This indicates that some staff may not have been adequately prepared to handle emergency situations.
6. Lack of proactive planning: The facility appeared to be unprepared for the admission of a resident with a tracheostomy, as evidenced by the lack of staff training, insufficient emergency equipment, and incomplete facility assessment.
These shortcomings collectively contributed to the facility’s inability to provide proper care for the resident during the respiratory emergency, ultimately leading to the resident’s death.
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