Licensed Practical Nurse Unit Manager #294 brought a size #4 tracheostomy tube with a cuff to Resident #77's bedside during a federal inspection on August 12, stating it was the type the resident used. But the resident didn't have a cuffed tracheostomy and had no physician's order for one.
The resident, admitted in March 2023 with anoxic brain damage and chronic obstructive pulmonary disease, depends on staff for all daily activities and requires a tracheostomy to breathe. Federal inspectors found the facility failed to keep proper backup equipment available as required by both the resident's care plan and facility policy.
At 7:20 a.m. during the inspection, Licensed Practical Nurse #234 confirmed there was no extra tracheostomy tube available if Resident #77's current tube became dislodged. The nurse also acknowledged the facility doesn't always have the tracheostomy supplies needed for the resident.
A dislodged tracheostomy tube creates a breathing emergency. The resident's care plan from March 7, 2023, specifically required keeping an extra trach tube and obturator at the bedside, with instructions to attempt reinsertion if the tube gets coughed out.
More than an hour later, at 8:37 a.m., the unit manager appeared with what she claimed was the correct replacement tube. Instead, she brought equipment the resident couldn't use.
Cuffed tracheostomy tubes have an inflatable balloon that seals against the trachea wall, typically used for patients on ventilators or those at risk of aspiration. Uncuffed tubes allow air to pass around them and are used for patients who can breathe on their own or speak.
The resident had physician orders dating to January 2 for daily tracheostomy care and daily changes of a size #4 Shiley inner cannula. An August 11 order specified a trach size 4UN85H with inner cannula size Shiley #4-41C85 to be changed every shift. None of these orders mentioned a cuff.
The facility's own tracheostomy care policy, dated January 10, requires a replacement trach tube to be available at the bedside at all times. Federal inspectors documented the violation during a complaint investigation.
Resident #77 suffers from anoxic brain damage, a condition caused by lack of oxygen to the brain that can result in severe cognitive impairment. The resident also has intractable epilepsy and acute-on-chronic systolic heart failure, conditions that make proper respiratory care critical.
The resident's quarterly assessment revealed complete cognitive impairment and total dependence on staff for activities of daily living. Such vulnerable patients rely entirely on nursing staff to monitor their breathing equipment and respond to emergencies.
The inspection occurred as part of a complaint investigation, suggesting someone reported concerns about care at the 77-bed facility. Federal inspectors reviewed medical records, observed care, and interviewed multiple staff members to document the violations.
The wrong equipment type represents more than a simple mix-up. In a respiratory emergency, staff attempting to use a cuffed tube on a patient ordered an uncuffed one could delay critical care or cause complications.
The facility acknowledged through staff interviews that supply shortages affect their ability to maintain required emergency equipment. LPN #234's admission that the facility doesn't always have needed tracheostomy supplies suggests an ongoing problem rather than an isolated incident.
Federal regulations require nursing homes to provide safe and appropriate respiratory care. For residents with tracheostomies, this means having the exact type of backup equipment ordered by physicians immediately available.
The violation affected one of three residents reviewed for tracheostomy care during the inspection. Inspectors classified the harm level as minimal or potential for actual harm, but the consequences of inadequate respiratory equipment during an emergency could be severe.
The inspection documented systemic failures in respiratory care management. Staff didn't know what equipment the resident needed, couldn't locate proper backup supplies, and brought the wrong type of device when asked to correct the problem.
Resident #77 remains dependent on staff who demonstrated they cannot reliably identify or provide the correct breathing equipment during the federal inspection.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Carecore At Mary Scott from 2025-08-12 including all violations, facility responses, and corrective action plans.
