The Illinois Department of Health has cited and fined Bria of Wood River when staff failed to properly perform CPR on two residents with tracheostomies, placing breathing bags over their mouths instead of their tracheostomy tubes because they didn’t know how to attach the equipment and had never been trained. Both residents died after receiving inadequate respiratory ventilation during resuscitation attempts, with staff admitting they either didn’t provide any ventilation or placed the bag over the wrong airway.
The first resident was admitted with chronic obstructive pulmonary disease, asthma, and a tracheostomy. His assessment showed he was cognitively intact and independent with mobility. His care plan documented he was a full code, meaning all resuscitation efforts should be performed if needed.
When the resident was found unresponsive and appeared blue, staff initiated CPR. A registered nurse later stated “we tried to do CPR over his tracheostomy, but we did not have the correct tubing to attach it, so we just tried to cover the tracheostomy with a gloved hand and attempted ‘bagging’ (placing bag valve mask) over his mouth.” Even more troubling, a nursing assistant stated clearly that “staff did not provide any ventilation during CPR and only did chest compressions. There were multiple bags in the room, but none would fit over his tracheostomy. The one on the crash cart did not work either, so they continued with compressions, but did not provide any ventilation during the resuscitation.” Emergency medical services continued resuscitation efforts but the resident was pronounced dead.
The second resident was admitted with anoxic brain damage, paraplegia, respiratory failure, and a tracheostomy. His assessment showed he was severely cognitively impaired, completely dependent for mobility, and required high concentration oxygen therapy and tracheostomy care. His care plan documented he was a full code.
When nursing assistants were providing care to this resident, they found him unresponsive and alerted a nurse. However, the assigned nurse was on break at the time.
A registered nurse from another unit started chest compressions while a nursing assistant attempted to provide breathing support. The nursing assistant explained what happened: “I started bagging the resident by mouth. I was not aware the bag had to be on the tracheostomy. I don’t even know how to attach the thing. I have never bagged a trach before. I think that is something we need to be educated on. None of us in there knew. I even asked. The nurse gave me the oxygen and I just took the bag and went with the mouth because that’s all I knew how to do. The nurse said she did not know how to attach it either.”
The registered nurse confirmed this account, stating “there was tube feeding coming out of the resident’s trach, so they just placed the respiratory bag over his face and turned the oxygen up.”
The fire department’s incident report revealed the severity of the problem: “Fire department units arrived on scene and found staff bagging the patient’s mouth and performing CPR on the patient while he was still in bed. Staff states they were bagging the patient’s mouth and not his trach tube due to secretions coming from the tube while CPR was being performed.” The fire department crew took over, noting the resident “was cold to the touch” when they arrived. They “took the bag valve mask off the patient’s mouth, mask was removed, and the bag valve mask was connected to the patient’s trach tube.” Despite following advanced cardiac life support protocols, the resident remained in asystole and medical control advised crews to terminate resuscitation efforts. The resident was pronounced dead.
The local fire department chief stated clearly that when his staff arrived, “facility staff were bagging the resident with the bag valve mask over the naso-oral pharynx which is not the standard place for the bag valve mask when a resident has a tracheostomy. The bag valve mask should have been via tracheostomy.”
When facility leadership was interviewed, they acknowledged the failures. The assistant director of nursing stated “there is a bag that goes over the tracheostomy when you provide CPR.” The director of nursing stated “there is a bag that goes on the trach, and those bag valve masks should be at bedside” and admitted she “was not previously informed of any issues with staff getting the bag valve masks on the tracheostomy.” The administrator stated “standard CPR protocol should be followed for residents with tracheostomies, but the respiratory bag should go over the tracheostomy site or the residents would not be getting air.” The medical director stated “he would expect staff to know how to perform CPR on residents with tracheostomies and would expect the facility to have the necessary equipment and supplies for both maintenance and emergent situations.”
Investigators also discovered that several nursing assistants did not have proper CPR certification from the American Red Cross or American Heart Association with hands-on, in-person training, despite the facility’s policy requiring it. The facility’s own tracheostomy care policy stated “it is the policy of this facility that residents with tracheostomies receive care to maintain a patent airway,” and the Code Blue policy instructed staff to “provide 2 breaths via ambu or manually if ambu is not available” and “continue CPR per BLS guidelines until EMS arrives.”
The facility failed on multiple critical levels: staff were not trained on how to perform CPR on residents with tracheostomies, the facility either didn’t have the correct equipment available or staff didn’t know how to use it, some staff lacked proper CPR certification, and leadership was unaware of these gaps until two residents died.
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