IDPH has cited and fined Landmark of Richton Park nursing home after a resident there died after a respiratory therapist cut sutures to a fresh tracheostomy without a physician order, leading to the loss of the airway and cardiac arrest.
A tracheostomy is a surgically-created airway. A surgeon cuts a hole, or stoma, in the front of the neck and through the trachea. A tube is then placed in the hole and allows the person to breathe through the hole. A tracheostomy is commonly used for ventilator-dependent patients to reduce complications associated with the use of a ventilator.
The tracheotomy tube actually consists of three parts. One is known as the outer cannula. The outer cannula has a neck plate flange which is stitched into place in the hole (or stoma) in the neck at the time of surgery. There is an inner cannula which fits inside the outer cannula and can be removed and cleaned. Finally, there is an obturator which is used only while the inner cannula is being placed. After it is placed, it is removed and disposed of.
Because the hole (or stoma) is a surgical wound, it must be given time to heal. Premature removal of the stitches can cause subcutaneous emphysema, or leaking of air under the soft tissues. Removal of the tube is not recommended for several days after initial placement because this can lead to rapid loss of the airway.
The resident at issue was admitted to the nursing home the day before the incident with a newly-created tracheostomy. During rounds, the wound care nurse advised the respiratory therapist that dressing wound did not look like it had been cleaned. The respiratory therapist saw that there was some dried blood in the area and decided to clean it. She asked the wound care nurse to borrow a pair of scissors so that she could cut a resident’s sutures. The wound care asked if was okay to do and the respiratory therapist said yes. She then proceeded to cut all of the sutures and clean the area.
Later that day, the alarms to the ventilator went off. The respiratory therapist went in and found that the resident was having a hard time breathing. Believing that the resident had a mucus plug (an accumulation of mucus in the airway which restricts airflow), she attempted to suction out the airway but did not get anything out and was not able to see the plus. She called for help and the rest of the staff responded. According to the respiratory therapist, the staff attempted to remove and replace the tracheostomy tube and ventilate the resident using an ambu-bag. However, there was resistance when they squeezed the bag on the ambu-bag, indicating that there was a loss of the airway. The resident began to turn blue and her face began to swell as they attempted to ventilate the resident.
Paramedics arrived, and they recorded on their report that the staff told them that the respiratory therapist had been the one to remove the tracheostomy tube. The paramedics were unable to re-establish the airway, and the resident went into cardiac arrest. She was brought to the hospital, but did not survive. When the resident arrived at the hospital, the staff noted extensive evidence of subcutaneous emphysema.
There are a number of issues with the care that this resident received. First, the sutures for the tracheostomy were removed prematurely, and done so without a physician order. Second, the tracheostomy tube was removed during the resuscitation effort. This likely contributed to the loss of the airway. It would be critical in any nursing home abuse and neglect lawsuit to determine exactly who removed the tracheostomy tube, as respiratory therapists often work for an outside company. Finally, the nurse provided the scissors to the respiratory therapist when she was likely aware that removing the sutures was inappropriate and that there was no physician order for doing so.
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