SAN ANTONIO, TEXAS - Federal inspectors documented critical respiratory care failures at The Rio at Mission Trails nursing facility that resulted in a resident's death, finding the facility lacked basic monitoring protocols and left a vulnerable resident unattended during a dangerous medical procedure in February 2025.
Resident Death During Unmonitored Breathing Trial
A resident with multiple serious health conditions died after facility staff left her alone during a tracheostomy capping trial, a procedure where the breathing tube opening is temporarily blocked to test if a patient can breathe independently. The resident, who had previously experienced strokes, respiratory failure, and required mechanical ventilation support, was found unresponsive approximately 30-39 minutes after being left unattended during her third capping trial on the morning of the incident.
Medical records showed the respiratory therapist started the capping trial at 11:36 AM, briefly checked on the resident at 11:59 AM, then discovered her unresponsive with no pulse at 12:38 PM. Despite CPR efforts and emergency transport to the hospital, the resident experienced severe brain damage from oxygen deprivation. Hospital records documented that she had been without oxygen to her brain, resulting in anoxic brain injury. The resident died at the hospital several days later.
The inspection revealed that during the first two capping trials, different respiratory therapists had remained with the resident for the entire duration - one therapist stayed for the full 30 minutes during the first trial, and another therapist remained present during the second trial when family members were also at bedside. However, on the fatal third trial, the respiratory therapist left after starting the procedure and only performed sporadic checks.
Complete Absence of Safety Protocols and Monitoring Equipment
Investigators discovered The Rio at Mission Trails had no written policy or procedure for conducting capping trials at the time of the incident, despite having 18 residents with tracheostomies in their respiratory unit. Staff members interviewed confirmed they were unaware of any facility protocols and relied solely on individual judgment and physician orders that lacked specific monitoring requirements.
The facility failed to use available safety equipment during the dangerous procedure. Although the facility possessed an audible pulse oximeter that could have alerted staff to changes in the resident's condition, it was not utilized during any of the capping trials. The respiratory therapy director confirmed that the non-audible oximeter placed on the resident would not alarm if she experienced cardiac arrest or respiratory distress.
Tracheostomy capping trials require intensive monitoring because blocking the breathing tube can quickly lead to respiratory distress or failure if the patient cannot breathe adequately on their own. Standard medical practice requires continuous monitoring of oxygen saturation, heart rate, respiratory rate, and physical signs of distress, particularly during initial trials when patient tolerance is still being established. The facility's failure to maintain continuous monitoring or use alarm systems meant the resident experienced cardiac arrest without any staff awareness for an extended period.
Family Misled About Safety Measures
The resident's family members reported being explicitly assured by facility leadership that staff would remain present throughout all capping trials. According to family interviews, both the respiratory therapy director and rehabilitation director promised continuous staff presence during multiple meetings before the trials began. The family expressed particular concern because the resident could not communicate verbally or use a call light to summon help if she experienced distress.
The resident's representative stated, "I was assured that staff would be present all the time" and added that if he had known the resident would be left alone, he would not have permitted the third trial. Family members had been present during the second trial and witnessed appropriate monitoring, leading them to believe this level of care would continue. They were not invited to attend the fatal third trial and were unaware it was being conducted without supervision.
The respiratory therapy director later denied making any commitment to maintain continuous staff presence during trials, contradicting the family's account. This discrepancy highlighted the facility's failure to establish clear communication protocols and obtain proper informed consent for high-risk procedures.
Medical Analysis Reveals Preventable Tragedy
The resident's complex medical history included quadriplegia from stroke, diabetes, hypertension, deep vein thrombosis, seizures, and chronic respiratory failure requiring tracheostomy. These conditions significantly increased her risk during any respiratory intervention. When conducting capping trials on patients with such extensive comorbidities, continuous monitoring becomes even more critical as these patients have reduced physiological reserves to compensate for any breathing difficulties.
During normal capping trials, medical staff should remain at bedside for at least the first 10-15 minutes to assess initial tolerance, monitoring vital signs including pulse, oxygen saturation, respiratory rate and quality, and lung sounds. For high-risk patients, continuous monitoring throughout the trial is standard practice. The facility's approach of leaving the resident unattended for extended periods violated basic respiratory care standards.
The pulmonologist who evaluated the resident acknowledged that given the cardiac arrest that occurred, "Yes staff should have been present all the time" and confirmed the facility needed a formal capping policy. Even the facility's own respiratory therapists, when interviewed, stated that initial capping trials typically require 100% staff presence, with subsequent trials depending on how well the patient tolerated the first attempt.
Additional Issues Identified
The inspection also classified this incident under the facility's neglect policies, as the failure to provide necessary monitoring and care to prevent physical harm met the definition of neglect under federal regulations. Multiple respiratory therapists confirmed they had not received training on capping procedures until after the incident occurred.
The facility's investigation remained incomplete at the time of the inspection, with the medical examiner's determination of cause of death still pending. Documentation showed inconsistencies in monitoring records, with gaps in vital sign documentation during critical periods.
Following the incident, inspectors found the facility scrambling to implement basic safety measures that should have been in place, including developing written procedures for capping trials, acquiring proper monitoring equipment, and training staff on respiratory care protocols.
The immediate jeopardy designation was issued on the date of inspection at 5:00 PM, requiring the facility to develop and implement an immediate plan of correction. While the immediate jeopardy was removed after the facility submitted a plan of removal, the facility remained out of compliance, requiring ongoing monitoring to ensure the effectiveness of corrective measures.
Facility's Response and Corrective Actions
After the immediate jeopardy citation, The Rio at Mission Trails implemented several corrective measures including developing a written capping trial procedure, requiring respiratory therapists to remain at bedside for the first 10 minutes of trials and monitor patients every 30 minutes thereafter, and mandating use of audible pulse oximeters during all capping procedures.
The facility conducted training for all respiratory therapy and nursing staff on the new protocols and established a monitoring system to audit compliance. However, these measures came too late for the resident who died, raising questions about why such basic safety protocols were not already in place at a facility caring for 18 residents with tracheostomies requiring complex respiratory care.
The investigation highlighted systemic failures in respiratory care management at the facility, from the absence of written protocols to the failure to use available safety equipment, inadequate staff training, and poor communication with families about the risks and safeguards for dangerous medical procedures. These deficiencies placed all residents requiring respiratory support at risk for serious harm or death.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Rio At Mission Trails from 2025-02-24 including all violations, facility responses, and corrective action plans.
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