Halstead Health: Emergency Equipment Not at Bedside - KS

The April inspection revealed that emergency tracheostomy supplies and an Ambu bag were not readily available at the bedside for Resident 2, who required immediate access to breathing assistance equipment.

Licensed Nurse G told inspectors the emergency supplies were stored under the Hoyer lift in the hallway and in the medication room. She explained that only hospice residents with tracheostomies had emergency kits at their bedside because hospice provided those supplies directly.

Administrative Nurse D confirmed to inspectors that tracheostomy care competency training occurred annually for nursing staff. But she said no emergency kit or Ambu bag was available at the bedside because the physician had instructed staff not to reinsert the tracheostomy if it came out. Instead, staff were told to immediately call 911.

The next morning, Administrative Nurse D clarified the Ambu bag's actual location. She said it was on the crash cart directly outside Resident 2's room, not at the bedside.

She verified that if staff needed the Ambu bag because Resident 2 was experiencing respiratory distress, they would have to move the Hoyer lift, uncover the cart, and wheel it into the room.

The facility's own respiratory care policy, dated on the inspection report, documented that the facility provided necessary respiratory care and services in accordance with professional standards of practice, the resident's care plan, and the resident's choice.

For residents with tracheostomies, seconds can determine survival during respiratory emergencies. The breathing tube inserted through the neck requires specialized equipment that must be immediately accessible when complications arise.

The inspection found minimal harm or potential for actual harm to residents, with few residents affected by the deficiency.

The storage arrangement meant that during a respiratory emergency, staff would need to perform multiple steps before reaching the equipment designed to help the resident breathe. Moving a Hoyer lift, uncovering medical equipment, and wheeling a cart into a room takes precious time when someone cannot breathe properly.

Administrative Nurse D's explanation revealed the contradiction in the facility's emergency preparedness. While the physician advised against reinserting a tracheostomy tube, the resident still needed immediate access to breathing assistance through the Ambu bag during respiratory distress.

The difference between hospice and non-hospice residents created an uneven standard of emergency preparedness. Hospice patients received bedside emergency equipment because their care provider supplied it, while other tracheostomy patients relied on equipment stored elsewhere.

Licensed Nurse G's description of the storage locations showed how emergency supplies were distributed throughout the facility rather than concentrated where the resident with the tracheostomy lived. The hallway storage under lifting equipment and medication room placement prioritized organization over emergency access.

The annual competency training for tracheostomy care indicated staff understood the medical procedures involved. However, the physical location of emergency equipment created a barrier between knowledge and implementation during critical moments.

Resident 2's situation highlighted how facility policies and physician orders sometimes conflict with emergency response needs. While calling 911 was the prescribed response for tracheostomy displacement, respiratory distress could still require immediate intervention with available equipment.

The inspection revealed that equipment accessibility, not just availability, determines whether residents receive timely emergency care. Having an Ambu bag on the same floor or in the same building means little if staff cannot reach it quickly when breathing problems develop.

Administrative Nurse D's verification that staff would need to move, uncover, and transport equipment during an emergency demonstrated how storage decisions directly impact resident safety during medical crises.

Full Inspection Report

The details above represent a summary of key findings. View the complete inspection report for Halstead Health and Rehabilitation Center from 2026-04-15 including all violations, facility responses, and corrective action plans.

Additional Resources

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