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Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 484.13, PATIENT RIGHTS, was out of compliance.

A-0131- Standard: Patient Rights: Informed Consent - the facility failed to implement measures to protect and promote each patient's rights. Specifically, the facility failed to ensure a standard process for notifying family members when patients experienced a change in condition or an event including when patients' artificial airways became dislodged or when unplanned decannulation occurred. There was lack of documentation that family members were notified of change in condition and unplanned decannulation events in 6 of 7 medical records reviewed in which patients experienced these negative events.

A-0144- Standard: Patient Rights: Care in a Safe Setting - the facility failed to ensure a safe patient care environment by the lack of investigation of an identified patient care issue, specifically, unplanned decannulations of patients' artificial airways. In 13 of 13 of these documented events, no investigation of the unplanned decannulations was conducted.

Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 482.23, NURSING SERVICES, was out of compliance.

A-0397 - Standard: Patient Care Assignments - The facility failed to ensure nursing staff assigned to patients with artificial airways received specialized training on how to prevent decannulation or dislodgement. This failure resulted in patients with multiple decannulations and emergent transfer to a different facility for a higher level of care.

A-0398 - Standard: Supervision of Contract Staff - The facility failed to ensure non-employee (contract) nursing personnel followed the procedure for requiring two staff members when repositioning. This failure resulted in unplanned decannulation of a high risk airway patient and a code blue (an emergent situation requiring resuscitation or immediate medical attention).

Based on the nature of standard level deficiencies referenced to the Condition, it was determined the Condition of Participation 482.57, RESPIRATORY CARE SERVICES was out of compliance.

A-1160 - Standard: Respiratory Care Services Policies - the facility failed to ensure Respiratory Therapy Services were provided in a safe and efficient manner pursuant to Medical Staff directives and policies and failed to identify unsafe practices and institute corrective actions. Respiratory Therapy Services did not act on the problem of increased unplanned decannulations (a potentially deadly complication when the patient's tracheostomy tube is displaced or dislodged). From 05/26/14 through 11/17/14, 13 unplanned decannulations occurred in the facility.

Based on interviews and document review, the facility failed to ensure a standard process for notifying patient representatives and family members when patients experienced a change in condition or negative events including when patients' experienced an unplanned decannulation. There was lack of documentation that family members were notified of unplanned decannulations in 6 of 7 medical records reviewed in which patients experienced these decannulations (Patients #1, #2, #3, #7, #8, and #9).

This failure created the potential for patients' health status to be unknown to family members who were to be included in care planning and decision-making.

FINDINGS:

POLICY

According to facility policy, Hospital Plan for the Delivery of Patient Care Services, staff will educate the patient and or person(s) who play a significant role in the patient's life in order to help improve patient health outcomes and will appropriately involve the patient and/or family in care decisions. The family will be encouraged to participate in planning for patients' care.

According to facility admission document, Designation of Individuals Allowed to Receive Updates, patients have the right to authorize family members and other interested parties to receive updates regarding their health status.

According to facility admission document, Patient Rights, patients and family members have the right to be informed about the outcomes of care, including unanticipated outcomes.

According to the facility's Medical Staff Rules and Regulations, the practitioner will be responsible for transmitting reports of the condition of the patient to relatives of the patient. The practitioner will involve the patient/family or guardian in the plan of care for the patient. Whenever these responsibilities are transferred to another staff member, a note covering the transfer of responsibility shall be entered on the order sheet of the medical record or entered into the electronic medical record.

1. The facility did not have a standard process to ensure notification of family members and patient representatives when patients experienced a negative event or change in condition.

a) On 11/25/14 at 10:05 a.m., an interview was conducted with the facility's Medical Director who stated patient representatives and family members should be notified if a patient experienced a negative event or change in condition. S/he stated direction about contacting family members was found in the Medical Staff Rules and Regulations. Family notification would be documented in physician progress notes. The Director stated this included events such as unplanned decannulations (a potentially deadly complication when the patient's tracheostomy tube is displaced or dislodged). The Director stated other staff could contact family members about an event but physicians would also contact family members to inform them about patients' medical status after an event. The Director stated physicians would call families as soon as a medical condition was resolved, including during the night unless there were instructions from family members not to call at specified times.

b) On 11/25/14 at 10:00 a.m., an interview was conducted with the facility's Director of Quality Management (DQM) who stated direction to physicians about contacting family members was found in the Medical Staff Rules and Regulations and families would be contacted "as soon as possible" after an event occurred. S/he stated nurses could call families to inform that an event occurred but the expectation was that the physician would contact the family to review the event and talk about the "course of treatment." The Director confirmed that upon admission, patients completed a document titled, Designation of Individuals Allowed to Receive Updates, which stated who should be contacted in the case of an event and that informing patients family members was part of patients' rights. The Director stated this communication to families would include unplanned decannulations.

c) Review of the medical record for Patient #2 revealed the patient was admitted to the facility on 10/23/14 due to a fall resulting in acute on chronic subdural hematoma, and post status craniotomy. The patient was described as unresponsive throughout the medical record and minimally responsive at his/her baseline. The record revealed the patient experienced an unplanned decannulation twice during hospitalization, on 10/27/14 and on 10/31/14.

On 10/27/14 the patient experienced desaturation (decreased oxygen levels), a code blue (an emergent situation requiring resuscitation or immediate medical attention) was called, and the patient's airway was replaced. Respiratory Therapy staff documented at 10:03 p.m., "family notified by RN." However, the identity of the Registered Nurse (RN), the actual time the call was placed, and which family member was notified was not documented.

No documentation was found in the medical record that the physician contacted the patient's representative to communicate this negative event or that the physician transferred this responsibility to another staff member. The medical record revealed 2 family members were documented on the list of designated individuals to receive health status updates, with the representative named first on the list.

The Medical Director, who was the patient's physician and was present when the event occurred, reviewed the medical record for Patient #2 and could not find documentation in his/her progress note that s/he notified the family of the decannulation on 10/27/14. S/he stated unplanned decannulations would be considered an event that families would be informed of.

d) Review of the medical record for Patient #3 revealed the patient was admitted on 10/01/14 with encephalopathy and acute respiratory distress. The record revealed the patient experienced 3 unplanned decannulations while in the facility. On 10/10/14 at 9:10 p.m., a rapid response was called due to desaturation. No documentation could be found in the medical record that the patient's family was informed of this event. There was no note that the physician transferred this responsibility to another staff member. The patient was described in the medical record as unresponsive before and after this event. The medical record revealed 2 family members were documented on the list of designated individuals to receive health status updates.

e) Review of the medical record for Patient #8 revealed the patient was admitted on 6/19/14 with acute on chronic respiratory failure, lower extremity cellulitis, and altered mental status. The record revealed the patient experienced 3 unplanned decannulations during the hospitalization (7/8/14, 7/10/14, and 7/12/14). No documentation could be found in the medical record that the patient's family was informed of these events. There was no note that the physician transferred this responsibility to another staff member. The medical record revealed 1 family member was documented on the list of designated individuals to receive health status updates.

f) Review of the medical record for Patient #1 revealed the patient was admitted on 10/16/14 with a recent traumatic brain injury and craniotomy. The record revealed the patient experienced a fall and unplanned decannulation on 10/20/14. There was documentation in the electronic record that a Licensed Practical Nurse (LPN) called the patient's representative and left a message for this individual to call the facility in order to "update on fall." No documentation was found in the medical record that the representative called the facility or that at any time this event was communicated to the representative. No documentation was found in the medical record that the physician contacted the representative to inform him/her about the fall and decannulation or that the physician transferred this responsibility to another staff member. The medical record revealed 3 family members were documented on the list of designated individuals to receive health status updates, with the representative first on the list.

g) Review of the medical record for Patient #7 revealed the patient was admitted on 8/25/14 after traumatic injuries resulting in rib fractures, bilateral pneumothorax, and right frontal hematomas. The record revealed the patient experienced an unplanned decannulation on 9/11/14. No documentation could be found in the medical record that the patient's family was informed of this event. A physician progress note dated 9/12/14 stated the patient "decannulated yesterday" but contained no documentation that the patient's family was informed of the event or that the physician transferred this responsibility to another staff member The medical record revealed 1 family member was documented on the list of designated individuals to receive health status updates.

h) Review of the medical record for Patient #9 revealed the patient was admitted on 07/02/14 after traumatic injuries including pelvic fractures, lower extremity fractures, and a subarachnoid hemorrhage. The record revealed the patient experienced an unplanned "self-decannulation" on 7/17/14. No documentation could be found in the medical record that the patient's family was informed of this event or that the physician transferred this responsibility to another staff member The medical record revealed 2 family members were documented on the list of designated individuals to receive health status updates.

Based on interviews and document review the facility failed to provide a safe patient care environment due to the lack of investigation of an identified patient care issue. Specifically, in 13 of 13 documented unplanned decannulations of artificial airways, no investigation of the events were conducted followed by actions to correct the issue and to ensure a safe patient care environment. (Patients #1, #2, #3, #7, #8, #9, #10, and #11.)

This failure created potential for negative outcomes to patients with artificial airways. This failure created situations in which patients airways were not functional and in some instances, respiratory code blues (emergent situations requiring resuscitation or immediate medical attention) were called for patients.

FINDINGS:

According to facility document, Hospital Plan for the Delivery of Patient Care Services, staff must participate in problem identification and resolution to ensure a high level of quality care. The goal of quality management is to improve patient care through an on-going, systematic process of monitoring and evaluation, which identifies patterns, trends, and problems and/or opportunities to improve. All departments are responsible for initiating activities to follow up on unusual occurrences or specific concerns or issues identified.

According to facility policy, Decannulation Prevention Program, the decannulation prevention program will be evaluated and re-evaluated to ensure the program is effective.

1. The facility identified a problem of increased unplanned decannulations (a potentially deadly complication when the patient's tracheostomy tube is displaced or dislodged), but did not investigate these negative events, did not evaluate the effectiveness of the decannulation prevention program, and did not take action to decrease the unplanned decannulation risk to patients.

a) On 11/25/14 at 10:00 a.m., an interview was conducted with the Director of Quality Management (DQM) who stated the facility began to receive more "respiratory" patients in May, 2014. Review of current admissions on 11/24/14 revealed 8 of 24 patients (30%) had an artificial airway. The DQM stated at the Patient Care and Safety Committee meeting held on 11/19/14, unplanned decannulations from October, 2014 were reviewed and an "uptick" in these events was noted. The DQM stated the increase in decannulations actually began in May, 2014 but were not identified as an issue until October, 2014. The DQM stated the number and severity of unplanned decannulations were looked at each month in the Patient Care and Safety Meeting, were discussed as incidents, but were not investigated to determine the cause of the incidents unless notable harm was caused to patients.

The facility's event reports were reviewed and it was noted the facility documented 13 unplanned decannulations from 5/26/14 through 11/17/14. Three of the patients listed experienced multiple unplanned decannulations.

The DQM stated s/he could not confirmed from the event reports for the 13 unplanned decannulations from 5/26/14 through 11/17/14 which staff members were providing care when the events occurred, which departments were involved (respiratory, nursing, etc.), or if contracted or agency nurses were involved in the events. The DQM stated s/he reviewed the decannulation event reports submitted by staff but did not interview staff to determine the actions that occurred that lead to the events. The DQM stated at the Patient Care and Safety Committee meeting held on 11/19/14, the Director of Respiratory Therapy Services would begin to look for trends in unplanned decannulations as this was identified as a problem.

b) On 11/26/14 at 8:18 am., an interview was conducted with the Director of Respiratory Therapy Services who stated since spring of 2014 the facility had admitted more neurologically impaired patients with artificial airways. S/he stated "this building has not seen this type of problematic airways before." The Director stated s/he was referring to the number of unplanned decannulations as well as the complexity of patients. S/he stated investigations of these events had not been conducted.

The Director stated at the Patient Care and Safety Committee meeting held on 11/19/14, s/he was charged with forming a committee to look for trends in unplanned decannulations. The Director stated the plan would be developed and would go back to the Medical Executive Committee for approval of forms, documents, and competencies and this approval would occur sometime in December, 2014. The Director acknowledged this planning process had not been started as of 11/24/14. The Director stated s/he was not given a deadline from the the Patient Care and Safety Committee for creating or implementing this plan. Additionally, the Director stated this had not been a previous topic of discussion in the Patient Care and Safety Committee meetings prior to 11/19/14.

c) On 11/28/14 at 4:33 p.m., an interview was conducted with the DQM who stated it was his/her responsibility to investigate patient events in order to ensure quality care was being provided to patients and s/he confirmed this was not done for the 13 documented unplanned decannulations because "no harm" was noted to patients. The DQM stated there was potential for harm to patients when unplanned decannulations occurred and these events should have been investigated.

The following are summaries from patient medical records of the 13 decannulations documented by the facility but not investigated:

d) Review of the medical record for Patient #2 revealed the patient was admitted on
10/23/14 due to acute respiratory failure with an artificial airway in place. The record revealed the patient experienced an unplanned decannulations on 10/27/14 and 10/31/14. During the event on 10/27/14 at 7:45 p.m., the patient experienced desaturation (decreased oxygen levels), a code blue was called, and the patient's airway was replaced. The second unplanned decannulation on 10/31/14 at 2:05 p.m., resulted in a code blue. Review of the code blue physician report, dated 10/31/14, revealed prior to the event the patient had a PICC (peripherally inserted central catheter) line placed and the tracheostomy became "dislodged during positioning for the procedure or from traction on the tubing."

e) Review of the medical record for Patient #3 revealed the patient was admitted on 10/01/14 due to encephalopathy and acute respiratory distress with an artificial airway in place. A code blue was called on 10/03/14 at 2:00 a.m. after the patient was turned by staff and appeared to have difficulty breathing. The patient was transferred emergently to another facility. Further review of the medical record revealed the patient was readmitted to the facility on 10/10/14 at 1:07 p.m. On 10/10/14 at 9:10 p.m., a rapid response was called due to desaturation. Documentation in a Pulmonary Critical Care progress note on 10/10/14 stated "Apparently the patient's trach became dislodged after turning." Documentation in a Primary Care progress note dated, 10/11/14, referencing the event on 10/10/14, stated the patient's trach was dislodged "again while turning patient." Continued review of the medical record revealed a rapid response was called on 10/30/14 at 1:10 p.m. due to the patient removing his/her trach.

f) Review of the medical record for Patient #8 revealed the patient was admitted on 06/19/14 due to respiratory distress with an artificial airway in place. The record revealed an unplanned, self-decannulation event on 07/08/14 at 11:59 p.m. The patient had a sitter at the time of the event. On 07/10/14 at 3:55 p.m. another unplanned, self-decannulation event was noted and the patient was placed in bilateral restraints. On 07/12/14 at 9:50 p.m., the record revealed respiratory therapy was called to the patient's room due to an unplanned decannulation.

g) Review of the medical record for Patient #1 revealed the patient was admitted on 10/16/14 with a recent traumatic brain injury and craniotomy. The record revealed the patient experienced a fall and decannulation of his/her artificial airway on 10/20/14. The nurse's note dated 10/20/14 at 6:48 p.m., revealed the patient was found on the fall mat beside the bed, which had 4 bed side rails in the up position. No injuries were noted and respiratory therapy reinserted a new artificial airway.

h) Review of the medical record for Patient #7 revealed the patient was admitted on 8/25/14 after traumatic injuries resulting in rib fractures, bilateral pneumothorax, and right frontal hematomas. The record revealed the patient experienced an unplanned decannulation on 9/11/14. The nurse's note dated 09/11/14 at 2:20 p.m., revealed the "patient was found with trach out," the patient "looked fine" and respiratory therapy staff reinserted the artificial airway without difficulty.

i) Review of the medical record for Patient #9 revealed the patient was admitted on 07/02/14 after traumatic injuries including pelvic fractures, lower extremity fractures, and a subarachnoid hemorrhage. The record revealed the patient "self-decannulation" on 7/17/14 at 2:30 a.m. The nurse's note documented at this time stated the patient was found lying in bed with his/her c-collar off and had removed his/her artificial airway.

j) Review of the medical record for Patient #10 revealed the patient was admitted on 04/15/14 for weaning of mechanical ventilation, physical, occupational, and speech therapy and continued antibiotics for recent pneumonia. Medical record review revealed on 06/13/14 at 8:50 a.m., the patient was "found decannulated" and his/her oxygen saturation was 30% with no heart rate noted and no spontaneous respirations. The patient was bagged until his/her saturation level returned to 100% and respirations were spontaneous. A physician progress note dated 06/13/14 revealed the patient was found in acute respiratory distress and unresponsive and it was noticed the patient "self-decannulated his/her artificial airway."

k) Review of the event report for Patient #11 revealed on 5/26/14 at 10:45 p.m., the patient was attempting to turn in bed and "pulled out" his/her artificial airway. Respiratory Therapy staff replaced the airway and there was no "negative effect" on the patient.

Based on interviews and document review, the facility failed to ensure nursing personnel received the training required to meet the individual and specialized needs of patients with a complex artificial airway in 7 of 7 medical records for patients who experienced unplanned decannulations. (Patient's #1, #2, #3, #7, #8, #9 and #10).

This failure resulted in repeated unplanned decannulations or dislodgements of the patient's artificial airways and negative patient outcomes.

Findings:

FACILITY POLICY

According to, Hospital Plan for the Delivery of Patient Care Services, Nursing: The Chief Clinical Officer will ensure the quality of nursing standards of patient care, treatment, and practice by incorporating current nursing research findings, nationally recognized professional standards, and other literature into the policies and procedures governing the provision of nursing care

Clinical services and departments are aligned under the direction of the Chief Clinical Officer.

1. The facility failed to ensure nursing staff assigned to patients with artificial airways received specialized training on how to prevent multiple unplanned decannulations (a potentially deadly complication when the patient's tracheostomy tube is displaced or dislodged).

a) Review of the medical record for Patient #2 revealed the patient was admitted on
10/23/14 due to acute respiratory failure with an artificial airway in place. The record revealed the patient experienced unplanned decannulation of his/her artificial airway twice during hospitalization, on 10/27/14 and 10/31/14. During the event on 10/27/14 at 7:45 p.m., the patient experienced decreased oxygen levels (desaturation). A code blue (an emergent situation requiring resuscitation or immediate medical attention) was called, and the patient's airway was replaced.

Subsequently on 10/31/14 at 2:05 p.m. a second code blue was called. Review of the physician report, dated 10/31/14, revealed the patient just had a PICC (peripherally inserted central catheter) line placed and the tracheostomy (artificial airway) became "dislodged during positioning for the procedure or from traction on the tubing."

There was no evidence the facility identified and provided staff training to decrease the likelihood of recurrent unplanned decannulations.

b) Review of the medical record for Patient #3 revealed the patient was admitted on 10/01/14 due to encephalopathy and acute respiratory distress with an artificial airway in place. A code blue was called on 10/03/14 at 2:00 a.m. after the patient was turned and appeared to have difficulty breathing and experienced pulseless electrical activity (PEA). The patient was transferred emergently to a different facility for a higher level of care.

Further review of the medical record revealed the patient was readmitted to the facility on 10/10/14 at 1:07 p.m. A rapid response was called due to the patient's desaturation on 10/01/14 at 9:10 p.m. Review of a Pulmonary Critical Care progress note, dated 10/10/14, revealed "Apparently the patient's trach[eostomy] became dislodged after turning." The Primary Care progress note dated, 10/11/14, showed the patient's tracheostomy was dislodged "again while turning patient."

There was no evidence the facility identified and provided staff training after Patient #3's initial unplanned decannulation and emergent transfer, to decrease the likelihood of additional unplanned decannulations with his/her readmission.

c) On 11/25/14 at 9:45 a.m., an interview with the Registered Nurse Education Coordinator was conducted. S/he stated training on turning patients with artificial airways would be provided upon new hire and no ongoing training was provided.

2. The facility failed to identify an increase in patient decannulations and evaluate current nursing practice and implement new processes to ensure patient's artificial airways were protected if indicated.

a) Review of the medical record for Patient #10 revealed the patient was admitted on 04/15/14 for weaning of mechanical ventilation, physical, occupational, and speech therapy, and continued antibiotics for recent pneumonia. Medical record review revealed on 06/13/14 at 8:50 a.m., the patient was "found decannulated" and his/her oxygen saturation was 30% with no heart rate noted and no spontaneous respirations. The patient was bagged until his/her saturation level returned to 100% and respirations were spontaneous. A physician progress note dated 06/13/14 revealed the patient was found in acute respiratory distress and unresponsive and it was noticed the patient self-decannulated his/her artificial airway.

b) Review of the medical record for Patient #1 revealed the patient was admitted on 10/16/14 with a recent traumatic brain injury and craniotomy. The record revealed the patient experienced a fall and unplanned decannulation of his/her artificial airway on 10/20/14. The nurse's note dated 10/20/14 at 6:48 p.m., revealed the patient was found on the fall mat beside the bed, which had 4 bed side rails in the up position. No injuries were noted and respiratory therapy reinserted a new artificial airway without difficulty.
c) Review of the medical record for Patient #7 revealed the patient was admitted on 8/25/14 after traumatic injuries resulting in rib fractures, bilateral pneumothorax, and right frontal hematomas. The record revealed the patient experienced unplanned decannulation of his/her artificial airway on 9/11/14. The nurse's note dated 09/11/14 at 2:20 p.m., revealed the "patient was found with trach out," the patient "looked fine" and respiratory therapy staff reinserted the artificial airway without difficulty.
d) Review of the medical record for Patient #9 revealed the patient was admitted on 07/02/14 after traumatic injuries including pelvic fractures, lower extremity fractures, and a subarachnoid hemorrhage. The record revealed the patient "self-decannulation" his/her artificial airway on 7/17/14 at 2:30 a.m. The nurse's note documented at this time stated the patient was found lying in bed with his/her c-collar off and had removed his/her artificial airway. The patient was confused but "easily re-oriented" and bilateral wrist restraints were placed per the patient's request.
e) Review of the medical record for Patient #8 revealed the patient was admitted on 06/19/14 due to respiratory distress with an artificial airway in place. The record revealed a self-extubation and decannulation event on 07/08/14 at 11:59 p.m. The patient had a sitter at the time of the event. On 07/10/14 at 3:55 p.m. another self-decannulation event was noted and the patient was placed in bilateral restraints. On 07/12/14 at 9:50 p.m., the record revealed respiratory therapy was called to the patient's room due to an unplanned decannulation.

f) On 11/25/14 at 1:19 p.m., an interview with the Education Manager was conducted. S/he stated they would perform a needs assessment with the staff and check with the managers to see what the needs are, and would develop education from there. Further, the EM stated the issue of unplanned decannulation has not been on his/her radar and was not able to identify any patient care issues that were.

The annual nursing competency document was reviewed. There was no evidence of decannulation prevention training conducted. The annual competency was focused on tracheal suctioning and skin care around the tracheostomy. The EM could not provide a date for when the last training on decannulation was provided to the nursing staff and again stated it wasn't on his/her plan.

g) On 11/25/14 at 3:10 p.m., an interview with the Chief Clinical Officer (CCO) was conducted. The CCO stated s/he had seen an "upsurge in patients decannulating themselves and we need to do something quickly." S/he stated as part of a plan, all respiratory therapy staff had gone through an unplanned decannulation competency with the Director of Respiratory (DOR) and this would be available to review in the training files. The CCO stated the DOR was given 2 (two) weeks for the training to be completed. S/he stated they had not had a chance to do any training or competency with nursing staff yet and that would be part of the training in December.

h) On 11/25/14 at 4:08 p.m., review of ten Respiratory Therapist training files was conducted. The review revealed no evidence respiratory staff received training on unplanned decannulation prevention.

i) On 11/26/14 at 8:18 a.m., an interview with the DOR was conducted. The DOR stated s/he was given the responsibility to train staff on how to care for a patient with an artificial airway. The training plan was due in December 2014 and would have gone to the Medical Executive Committee (MEC) meeting for approval and then to the education department to set up a training schedule. The DOR stated the training would have been completed by the first week in January 2015.

Based on interviews and document reviews, the facility failed to ensure contract personnel were oriented to and adhered to the facility's policies and procedures.

This failure resulted in unplanned decannulation of a high risk airway patient.

Findings:

FACILITY POLICY

According to Decannulation Prevention Program, last revised 08/2013, the facility considered all patients who had an artificial airway to be at high risk for decannulation. Additionally, any patient who would be considered at risk would always have at least two staff members assist with turning and repositioning.

1. The facility failed to ensure non-employee (contract) nursing personnel were oriented and followed the procedure which required two staff members for repositioning patients with an artificial airway.

a) On 11/24/14 at 3:27 p.m., a review of Patient #2's medical record was conducted. The review revealed s/he had 2 (two) episodes of unplanned decannulations (a potentially deadly complication when the patient's tracheostomy tube is displaced or dislodged), 10/27/14 and 10/31/14. The code blue note, dated 10/31/14, read the patient just had a PICC (peripherally inserted central catheter) line placed and a code blue (an emergent situation requiring resuscitation or immediate medical attention) was called for the absence of respirations and a thready or absent pulse. The documentation further read the tracheostomy was dislodged during positioning for a procedure or from traction on the tubing.

b) On 11/25/14 at 9:03 a.m., an interview with the Director of Quality Management (Employee #3) DQM was conducted. S/he stated Patient #2 had an ill-fitting tracheostomy and when Registered Nurse #7 (RN) moved the bed the tracheostomy became dislodged. The DQM stated RN #7 was a contracted employee and the company was new to the facility.

During the same interview, the DQM stated RN #7 should have reported to the Charge Nurse when s/he arrived at the facility and a facility registered nurse should have been present in the room when RN #7 (PICC nurse) started lowering the head of the bed. The DQM stated this was in violation of their policy.

c) On 11/25/14 at 2:03 p.m., an interview with the Education Manager (EM, Employee #1) and the DQM was held. The EM stated s/he had not conducted any education or orientation of contracted PICC nurses and the facility only received an attestation of their training from the staffing agency. In addition, the DQM stated s/he did not know if the PICC nurse (RN #7) knew of the facility's policy and could not furnish evidence that contract personnel received orientation to the facility or policies.

Based on interviews and document review the facility failed to ensure Respiratory Therapy Services were provided in a safe and efficient manner pursuant to Medical Staff directives and policies and failed to identify unsafe practices and institute corrective actions.

FINDINGS:

According to facility policy, Hospital Plan for the Delivery of Patient Care Services, each department is responsible for initiating activities designed to follow up on unusual occurrences or specific concerns or issues which may include performance improvement activities. Each department, as appropriate, will be represented on performance improvement teams.

According to facility policy, Decannulation Prevention Program, the facility will develop a multiple intervention program aimed at minimizing individual patients' risk of unintentional decannulation. There will be regular evaluation and re-evaluation of the program.

1. Respiratory Therapy Services did not act on the problem of increased unplanned decannulations (a potentially deadly complication when the patient's tracheostomy tube is displaced or dislodged). From 05/26/14 through 11/17/14, 13 unplanned decannulations occurred in the facility.

a) From 05/26/14 through 11/17/14 the facility documented 13 unplanned decannulations. As example:

- On 10/27/14, Patient #2 experienced an unplanned decannulation with desaturation (decreased oxygen levels), a code blue was called (an emergent situation requiring resuscitation or immediate medical attention), and the patient's airway was replaced. A second unplanned decannulation occurred on 10/31/14, which resulted in a code blue.

- On 10/03/14, Patient #3 experienced an unplanned decannulation after the patient was turned by staff and appeared to have difficulty breathing, experienced a PEA (pulseless electrical activity), and a code blue was called. On 10/10/14, the patient experienced decannulation and desaturation after being turned by staff and a rapid response was called. On 10/30/14 the patient removed his/her trach and a rapid response was called.

- Patient #8 experienced 3 self-decannulations (07/08/14, 07/10/14, and 07/12/14), at times when there was a sitter present in the room and also when the patient was in soft wrist restraints.

- Patients #1, #7, #9, #10, and #11 were found with decannulated airways during their hospitalizations.

b) On 11/26/14 at 8:18 a.m., an interview was conducted with the Director of Respiratory Therapy Services who stated beginning spring of 2014, the facility admitted more neurologically impaired patients with artificial airways. S/he stated "this building has not seen this type of problematic airways before." The Director stated s/he was referring to the number of unplanned decannulations as well as the complexity of these patients. The Director could not describe any new or additional training or education of direct care staff, including respiratory therapy staff, to address this increase in "problematic airways."

The Director stated training of the respiratory therapy staff for 2014 included use of the electronic patient record, the skin safe program, alarm fatigue, and a number of other topics but did not specifically address training and competencies to reduce the number of unplanned decannulations. The Director stated s/he was not aware of any trends from incident reports or patient care and safety issues that would require specific training of his/her staff for reducing unplanned decannulations.

Review of the Patient Care and Safety Committee meeting dated, 11/19/14, showed the Director of Respiratory Therapy Services was assigned to "head a committee" to provide a plan for decreasing unplanned decannulations.

The Director stated s/he was charged with forming this committee. The Director stated the plan would be developed and would go back to the Medical Executive Committee for approval of forms, documents, and competencies and this approval would occur sometime in December, 2014. The Director acknowledged this planning process had not been started as of 11/24/14. The Director stated s/he was not given a deadline from the the Patient Care and Safety Committee for creating or implementing this plan. Additionally, the Director stated this had not been a previous topic of discussion in the Patient Care and Safety Committee meetings prior to 11/19/14.

c) On 11/25/14 at 3:10 p.m., an interview was conducted with the Chief Clinical Officer (CCO), who stated s/he recognized issues with unplanned decannulations when s/he began his/her position at the facility in mid October, 2014. The CCO stated s/he spoke to the Directory of Respiratory Therapy Services about the unplanned decannulations and instructed the Director to "identify and fix the issue." The CCO stated all Respiratory Therapists were to complete "competency and training" regarding unplanned decannulations and the Directory of Respiratory Therapy Services was to ensure this occurred within 2 weeks. The CCO stated this 2 week time period had passed but could not give the date the 2 weeks began or ended.

During an interview on 11/26/14 at 8:18 a.m. with the Director of Respiratory Therapy Services, the Director stated s/he was not given the instruction by the CCO, or anyone in facility leadership, to train the respiratory therapy staff on any competencies, including competencies to reduce unplanned decannulations, "in a 2 week period."