Bayada Home Health Care Inc.

“Provide contact info other services CFR(s): 484.50(d)(5)(iii) (iii) Provide the patient and representative (if any), with contact information for other agencies or providers who may be able to provide care; and This Element is not met as evidenced by: Based on interview and record review, the agency failed to provide information on other community agencies who may be able to provide services to the patient for 1 of 2 patients (P7) reviewed for discharge. Findings include: P7’s plan of care (POC) dated 2/10/25 - 2/10/25, identified start of care (SOC) date of 2/15/23. P7’s transfer/discharge summary dated 4/10/25, indicated P7 was discharged from services on 4/8/25 due to schedule changes. The summary indicated P7 had no behaviors. P7’s medical record lacked documentation information about outside resources that might be able to continue to meet patient needs was provided at time of discharge. During an interview on 7/23/25 at 9:07 a.m., clinical manager (CM)-A stated P7 was discharged from services because there was no nurse to provide P7 the care he needed. We tried for 5 months to find a nurse to provide him care but we could not find one. We provided him with his discharge instructions, discharge summary and medication list when we discharged him. We did not reach out to any other agency to see if they could provide the care he needed and did not provide a list of community resources to him at time of discharge. Facility policy Client Discharge and Transfer-Medicare Certified Home Health and SNU Offices last revised 5/4/20, indicated a client could be transferred for the following reasons: 1. necessary for client welfare, 2. Could no longer pay for services, 3. provider deemed patient no longer needed skilled services, 4. client refused services, 5. client became disruptive, abusive or uncooperative to extent ability to care for patient was seriously impaired, or 6. the patient died. The policy lacked documentation related to discharge to due staffing concerns. When a patient would be discharged for a cause, the patient would be given a list of other agencies or providers who could possibly be able to provide the cares.”

“RN performs assessment CFR(s): 484.55(a)(1) A registered nurse must conduct an initial assessment visit to determine the immediate care and support needs of the patient; and, for Medicare patients, to determine eligibility for the Medicare home health benefit, including homebound status. The initial assessment visit must be held either within 48 hours of referral, or within 48 hours of the patient’s return home, or on the physician or allowed practitioner - ordered start of care date. This Element is not met as evidenced by: Based on interview and record review the home health agency failed to admit the patient within 48 hours of referral or obtain a provider order to delay admission for 6 of 6 patients (P1, P2, P3, P4, P7, P8) reviewed for admission. Findings include: P1: P1’s plan of care (POC) for certification period of 722/25 to 9/19/25 indicated a start of care (SOC) date of 6/29/18. P1’s referral form undated, indicated a referral to admit to services was received on 9/16/15 P1’s medical record lacked documentation of provider approval to delay admission over 48 hours from receiving the referral. During an interview on 7/22/25 at 9:58 a.m. client services manager (CSM) stated P1’s SOC date on the POC was incorrect and P1 started services on 11/3/15. P2: P2’s plan of care (POC) for certification period of 5/28/25 to 7/26/25 indicated a start of care (SOC) date of 7/14/21. P2’s referral form undated, indicated a referral to admit to services was received on 6/6/21. P2’s medical record lacked documentation of provider approval to delay admission over 48 hours from receiving the referral. P3: P3’s plan of care (POC) for certification period of 6/23/25 to 8/21/25 indicated a start of care (SOC) date of 7/14/21. P3’s referral form undated, indicated a referral to admit to services was received on 6/6/21. P3’s medical record lacked documentation of provider approval to delay admission over 48 hours from receiving the referral. P4: P4’s plan of care (POC) for certification period of 6/26/25 to 8/26/25 indicated a start of care (SOC) date of 8/11/21. P4’s referral form undated, indicated a referral to admit to services was received on 6/22/21 P4’s medical record lacked documentation of provider approval to delay admission over 48 hours from receiving the referral. During an interview on 7/22/25 at 9:58 a.m. client services manager (CSM) stated P1’s SOC date on the POC was incorrect and P1 started services on 11/3/15. P7: P7’s plan of care (POC) for certification period of 2/10/25 to 4/10/25 indicated a start of care (SOC) date of 2/15/23. P7’s referral form undated, indicated a referral to admit to services was received on 2/2/23. P7’s medical record lacked documentation of provider approval to delay admission over 48 hours from receiving the referral. P8: P8’s POC for certification period of 2/16/25 to 4/16/25 indicated a SOC date of 12/16/24. P8’s referral form undated, indicated a referral to admit to services was received on 1/19/23 P8’s medical record lacked documentation of provider approval to delay admission over 48 hours from receiving the referral. During an interview on 7/22/25 at 9:58 a.m. client services manager (CSM) stated all of the facility new patients take at least a month before they are admitted to services. They do not get orders to delay admissions from providers when it takes longer than two days to admit the patient. Agency policy Admission Criteria and Procedure-Medicare Certified Offices last revised 1/1/25, indicated all admissions would be completed within 4h hours of referral or return to client’s home and admission outside of the 48-hour time period would be communicated to the provider.”

“Only as ordered by a physician CFR(s): 484.60(b)(1) Drugs, services, and treatments are administered only as ordered by a physician or allowed practitioner. This Element is not met as evidenced by: Based on interview and document review, the agency failed to ensure visits were conducted in accordance with physician orders for 1of 7 patients (P7), failed to notify the physician when the visits were not conducted according to the plan of care (POC), and to educate the patient on the risks of missed visits or attempt to reschedule the missed visit. Findings include: P7’s plan of care (POC) for certification period 12/12/24 through 2/9/25, indicated a start of care (SOC) date 2/15/23. Diagnoses included encounter for attention to tracheostomy. Ordered services included skilled nursing visits (SNV) 8-16 hours per day and 3-7 days per week not to exceed 60 hours a week for 60 days. P7’s plan of care (POC) for certification period 2/10/25 through 4/10/25, indicated a start of care (SOC) date 2/15/23. Diagnoses included encounter for attention to tracheostomy. Ordered services included skilled nursing visits (SNV) 8-16 hours per day and 3-7 days per week not to exceed 60 hours a week for 60 days. P7’s calendar from12/1/24 to 4/10/25 indicated a visit was performed on 12/9/24 but no other visit was scheduled or performed after that date, until discharge on 4/10/25. Review of P7’s medical record indicated P7 did not receive an ordered visit the weeks of 7/14/24, 7/21/24, 7/28/24, 8/11/24, or 8/18/24. The medical record lacked evidence the physician had been notified of the missed visits until 5/13/25. The medical record lacked any documentation the appointments were rescheduled or educated on the risks related to missed visits. During an interview on 7/22/25 at 1:25 p.m., the scheduling manager (SM)-B stated if a nurse called off, we would notify the family or caregiver the nurse was not going to show up. Occasionally we would try to reschedule or get a different nurse to cover but not always. When there was no nurse to provide the care, it was up to the family to provide the specialized care the patient would need. We notify the provider on a weekly basis when missed visits occur for the prior week. Since the agency did not have a nurse for P7 we did not schedule appointments for a nurse to go out from the end of December 2024, to discharge in April 2024. We did not notify the provider about all of the missed visits until after P7 was discharged from the agency. Facility policy Missed Visits/Hours last reviewed 3/24/23, indicated the provider would be notified when the plan of care was altered related to fewer visits or hours of service were provided as ordered. At minimum, verbal or fax notification of the missed visit is made to the provider on a weekly basis.”

“Organization and administration of services CFR(s): 484.105 Condition of participation: Organization and administration of services. The HHA must organize, manage, and administer its resources to attain and maintain the highest practicable functional capacity, including providing optimal care to achieve the goals and outcomes identified in the patient’s plan of care, for each patient’s medical, nursing, and rehabilitative needs. The HHA must assure that administrative and supervisory functions are not delegated to another agency or organization, and all services not furnished directly are monitored and controlled. The HHA must set forth, in writing, its organizational structure, including lines of authority, and services furnished. This Condition is not met as evidenced by: Based on the number and/or severity of the deficiencies cited the home health agency failed to meet the Condition of Participation: Organization and Administration of Services at 42 CFR 484.105. The agency failed to provide timely call to 911, emergency medical services. Findings include: Refer to G984: Based on interview and document review the agency failed to ensure emergency medical services (EMS) 911 were initiated timely for 1 of 1 patient (P1) when P1 had an acute respiratory event. In addition, the registered nurse (RN)-A did not follow the agency training for respiratory emergencies.”

“Immediate reporting of abuse by all staff CFR(s): 484.50(e)(2) Any HHA staff (whether employed directly or under arrangements) in the normal course of providing services to patients, who identifies, notices, or recognizes incidences or circumstances of mistreatment, neglect, verbal, mental, sexual, and/or physical abuse, including injuries of unknown source, or misappropriation of patient property, must report these findings immediately to the HHA and other appropriate authorities in accordance with state law. This Element is not met as evidenced by: Based on interview and document review the home care agency failed to report an allegation of neglect for 2 of 2 patients (P1 and P2) reviewed when it was alleged registered nurse (RN)-A inverted a tracheostomy placement and failed to provide adequate emergency medical intervention during a respiratory failure event. Findings include: P1’s plan of care (POC) with certification period from 7/10/24 to 9/07/24, indicated P1 was diagnosed with dependence with respirator, attention to tracheostomy, gastrostomy, and seizure disorder. The POC further indicated P1 was to receive skilled nursing (SNV) 8-24 hours a day, 5- 7 days per week, up to 168 hours. The POC also indicated P1 was Full Code and did not have an advanced directive. The POC further directed staff P1 was to receive 1.5 liters (L) of continous oxygen via trach/vent and 1-3 L as needed and titrate up to maintain saturations of 93% or greater. Place client on vent if requiring 3 L for two hours or more during the day. Oxygen (O2) can also be applied for comfort. Monitor signs or symptoms of respiratory distress or respiratory illness and/or seizure activity. P1’s Abuse and Neglect Tool revised 8/03/24, indicated “client had a Hypoxic/decannulation event on 7-19-2024. Client hospitalized. Discharged home on 7-22-24. Re-hospitalized on 7-31-24 for uncontrolled seizures. Discharged home on 8-03-24.” The report further indicated there was no indicators of abuse, yet the patient was susceptible to abuse by other individuals, including other vulnerable adults or children assessed. Patient was assessed and no abused noted. A Coordination of Services Note dated 7/19/24, completed by CM-B indicated CM-B received phone call from licensed practical nurse (LPN)-A on 7/19/24 at 3:30 a.m., and LPN-A reported P1’s sisters just called her in a panic let her know that [P1] was being taken to the ER for a hypoxic event d/t (due to) saturations in “the 20’s” (normal level for oxygen level is 95 to 100%), “Family member (FM)-A stated the trach was all of the way out, per EMT (emergency medical technician) and FM-A stated she told the night nurse RN-A, and RN-A was surprised. On the call FM-A stated RN-A was not doing CPR correctly and she did not know anything!” During interview on 8/01/24 at 3:10 p.m. the agency administrator stated she thought P1’s incident was more of a medical emergency versus abuse or neglect at the time. The administrator stated cooperate completed an investigation and there were discrepancies with what the patient’s family members were saying what happened compared to the nurse’s report, so a report was not made. The administrator did state she was aware P1’s case manager did file a report to the state agency. P2’s POC with certification period from 6/17/24 to 8/15/24, indicated P2 was diagnosed with paralysis of vocal cords, epilepsy, and hydrocephalus (neurological disorder caused by an abnormal buildup of cerebrospinal fluid in the ventricles (cavities) deep within the brain). P2’s POC further indicated P2 received skilled nursing visits 8-24 hours per day, 3-7 days a week for 60 days. In addition, P2 had a tracheostomy tube and to maintain patency of Bivona (silicone tube construction allows the tube to remain flexible in the trachea) 6.0 cuffed trach inflated with one cubic centimeter (CC’s) of water. P2’s Abuse and Neglect Tool dated 7/12/24, indicated P2 felt safe at home, and there were no concerns with caregivers. In addition, the tool indicated there was no other concerns during the home visit. A Coordination of Services Note dated 7/07/24, completed by clinical manager (CM)-A indicated RN-A performed an unscheduled trach change for P2 as his high-pressure alarm was going off during the night shift on his ventilator machine. The CM-A stated he received a phone call from RN-B who noticed a vocalized sound from P2 that was different from normal and checked his trach and it was tied upside down, and the cuff was not inflated. The note indicated it was not sure how long the trach was upside down and the trach was placed with a new one and tied appropriately and inflated with a balloon with one milliliter (ml) sterile water and all vitals were within normal limits. The note further indicated the CM-A had RN-A came in 7/08/24 at 9:30 a.m. for retraining in the agencies lab to complete education and return demonstration for tracheostomy care and emergency protocols. RN-A completed all tasks successfully. During interview on 8/01/24 at 3:05 p.m., agency administrator stated a report was not made to the state agency in regard to P2 due to feeling it was an error, not abuse or neglect just an error on the nurse’s part. Agency Policy revised 2/08/23, indicated a field employee, who has reason to believe that a vulnerable adult is being or has been maltreated, or who has knowledge that a vulnerable adult has sustained a physical injury which is not reasonably explained will, immediately report the information to the office Director, Clinical Manager, or Client Services Manager who will then report the information to the common entry point either by telephone and verbal report, or electronic reporting. In addition, the law protects anyone under the age of 18 who is the subject of physical and sexual abuse, neglect, and endangerment which a parent, guardian, or custodian has inflicted, may inflict, permitted another person, or had reason to know another person may inflict. These such incidents must be reported to the Minnesota Department of Human Services.”

“In accordance with current clinical practice CFR(s): 484.105(f)(2) All HHA services must be provided in accordance with current clinical practice guidelines and accepted professional standards of practice. This Element is not met as evidenced by: Based on interview and document review the agency failed to ensure emergency medical services (EMS) 911 were initiated timely for 1 of 1 patient (P1) when P1 had an acute respiratory event. In addition, the registered nurse (RN)-A did not follow the agency training for respiratory emergencies. Findings include: P1’s plan of care (POC) with certification period from 7/10/24 to 9/07/24, indicated P1 was diagnosed with dependence with respirator, tracheostomy, gastrostomy, and seizure disorder. The POC further indicated P1 was to receive skilled nursing visits (SNV) 8-24 hours a day, 5- 7 days per week, up to 168 hours. The POC further indicated P1 was Full Code and did not have an advanced directive. The POC directed staff P1 was to receive 1.5 liters (L) of continuous oxygen via trach/vent and 1-3 L as needed and titrate up to maintain saturations of 93% or greater. Place client on vent if requiring 3 L for two hours or more during the day. O2 can also be applied for comfort. Monitor signs or symptoms of respiratory distress or respiratory illness and/or seizure activity. The POC indicated in the event of emergency obstruction of the airway, Accidental decannulation, or malfunction of the trach tube, attempt to reinsert routine trach size, if unsuccessful, reposition the head and neck and try again. If still unsuccessful, insert the 5.0 x 44 downsized trach, if still unsuccessful, thread the #10 French suction catheter through the smaller sized trach and use as a guide to assist in placing the smaller sized trach, either leave the catheter in and use to supply oxygen or remove and provide support with the hand ventilator and mask to either the intact natural air supply or the tracheal stoma. Administer CPR and activate emergency medical services (EMS). Notify the case manager (CM), primary care giver and physician for all unplanned trach changes. P1’s Treatment Record (TAR) dated from 7/18/24 to 7/19/24, indicated the following treatments were not signed off while RN-A was working. RN-A started her shift on 7/18/24 at 4:30 p.m. and ended at 7/19/24 at 3:14 a.m. when the paramedics arrived. It could not be verified that treatments were completed while RN-A was working. -SN (Skilled nurse) to assess client Q shift for suspect of abuse by another individual, including caregivers, and self-abuse pm (evening shift). -SN to document verification of rotated pulse oxygen every 4 hours and as needed. -Pulse oximeter continuous high heart rate 170 beats per minute (BPM) low heart rate 50 BPM, low oxygen saturation rates (o2 sats) 90% high 100% continuous pulse oximetry to be on when leaving the client in care of primary care giver (PCG), check alarm settings and function prior to reporting. -Trach tie changes q shift and as needed when soiling. -change 2 x 2 dressing with trach tie dressing q shift. -trach care by SN and secretions for client every 8 hours evening shift. -safe suction depth via 10 FR suction Cath 14 CM or the thick red line in the hub. -Ambi Vest (coughs or huff coughs to clear the mucus. Sessions last about 20 to 30 minutes.) every evening. -cough and assist to be completed with three rounds breaths a cycle stetting with exhale and inhale. -when ventilator on make sure whisper swivel/exhalation valve is in place with Flextend. -At 11:00 p.m. verify trach cuff is inflated when on vent and deflated when client is off the vent. -SN to consistently verify that the tubing circuit does not have too much water, drain the water away from the patient and into the sterile water bottle that is on the floor by the humidifier. The ambulance run sheet dated 7/19/24 indicated EMS received a call at 3:09 a.m. to dispatch to P1’s home for a breathing problem. EMS arrived on scene at 3:14 a.m., finding P1 lying in bed, P1 was connected to the turned off ventilator with no ventilations being provided. EMS departed P1’s home at 3:35 a.m., and P1 was transferred to the hospital at 4:15 a.m. The EMS ambulance run sheet indicated two attempts to intubate P1 and were successful at 3:28 a.m. P1 desaturated during the transfer and was suctioned with no improvement. P1’s vital signs varied when EMS arrived until the hospital transfer. The first reading at 3:18 a.m. indicated a pulse (heart rate) at 132 and oxygen saturations (o2 sats) at 43%, the last reading at 3:40 a.m. indicated a pulse (heart rate) at 130 and oxygen saturations (o2 sats) at 7%. Per P1’s TAR P1’s vital parameters were high heart rate 170 beats per minute (BPM) low heart rate 50 BPM, low oxygen saturation rates (o2 sats) 90% low, high 100%. A Coordination of Services Note dated 7/19/24, completed by case manager (CM)-B indicated CM-B received phone call from licensed practical nurse (LPN)-A on 7/19/24 at 3:30 a.m., and LPN-A reported P1’s family member (FM)-A just called her in a panic letting her know that [P1] was being taken to the ER for a hypoxic event d/t (due to) saturations in “the 20”s” (normal level for oxygen level is 95 to 100%), “Family member (FM)-A stated the trach was all of the way out. Per EMT (emergency medical technician) FM-A stated she told the night nurse RN-A, and RN-A was surprised. On the call FM-A stated RN-A was not doing CPR correctly and she did not know anything!” P1’s hospital discharge summary dated 7/19/24, indicated P1 was admitted with diagnoses of acute hypoxic respiratory failure due to trach dislodgement, emergency medical services were called, P1 was intubated through his tracheostomy site, however saturations did not come up to normal ranges with his intubations. His saturations were as low as 9%. P1 was a subsequent transfer to the hospital and in the ED (emergency department) P1 was successfully intubated and his saturations came up. The neurologist consultation report indicated it was unclear the amount of neurological insult P1 had due to this hypoxic event. P1 had one seizure, however he was at his neurological base line per family members. The report indicated P1 was transferred to another hospital. P1’s transferring discharge summary dated 7/22/24, indicated P1 was admitted on 7/19/24 for acute dislodgement of tracheostomy, prolonged hypoxic event with intractable epilepsy. The summary further indicated a follow up appointment with neurology on 7/31/24, which provided a new seizure action plan for the home health agency. P1’s Abuse and Neglect Tool revised 8/03/24, indicated “client had a Hypoxic/decannulation event on 7-19-2024. Client hospitalized. Discharged home on 7-22-24. Re-hospitalized on 7-31-24 for uncontrolled seizures. Discharged home on 8-03-24.” The report further indicated there was no indicators of abuse, yet the patient was susceptible to abuse by other individuals, including other vulnerable adults or children assessed. Patient was assessed and no abused noted. During an interview on 7/31/24 at 9:15 a.m., agency administrator stated P1 had a medical emergency and was aware the incident was reported to the Minnesota Department of Health from P1’s case manager. The administrator further stated P1’s trach came out. P1 received 24 hours skilled nursing services from the agency, had a ventilator at night, and had a tracheostomy. The administrator further stated it was unknow what happened due to the conflicting information they received, and their legal department completed an investigation. The administrator stated the registered nurse (RN)-A who was involved, started with the agency at the branch office in St. Paul in January 2024, and then transferred to our office in June 2024 and was not sure of the reason. On the night of the incident P1’s parents went on a vacation and needed a nurse the night of 7/19/24, so the client services manager (CSM) put out a message for staff if they wanted to pick up the shift. The administrator stated RN-A picked up the shift and received a home orientation from the day shift licensed practical nurse (LPN)-A at approximately 4:30 p.m. who was familiar with P1, and RN-A took over care around 5:00 p.m. The administrator further indicated about a month ago RN-A put a trach in a patient upside down and she was retrained on trach care and emergencies in the agency lab and completed return demonstration successfully. During an interview on 7/31/24 at 11:44 a.m., CM-B stated RN-A has not worked with any other patients since the incident occurred with P1. CM-B stated she was on-call 7/19/24 and spoke with FM-A. FM-A stated she had concerns with RN-A and called 911 during the incident. CM-B was notified of the incident around 3:30 a.m. by LPN-A. CM-B stated during the incident that occurred on 7/19/24, RN-A did not send P1’s emergency bag, which was required for P1 to have his supplies, and P1’s family members had to go back to his home to get the emergency bag for P1’s tracheostomy size and equipment. During an interview on 7/31/24 at 12:55 p.m., CM-A stated he took over P1’s case at the end of May 2024, and was informed by FM-A she was trying to change P1 when his oxygen levels were getting low and began to Ambu bag (resuscitation in emergency situations to provide respiratory support to patients who are unable to breathe on their own) P1, and she was changing from breaths to cath to suction him. RN-A connected P1’s oxygen to the Ambu bag, she connected the tubbing to the oxygen concentrator instead of the liquid oxygen. CM-A stated he teaches the nurses in class they should connect the Ambu bag directly to the portable oxygen tank to get immediate 100% oxygen and not use the concentrator during an emergency event. CM-A further stated he had concerns when RN-A was attempting to Ambu bag P1, the trach might not have been in place since his oxygen levels, according to the family members present in the room were going so low. CM-A stated he was concerned she was not checking for proper placement of the trach prior to using the Ambu bag. CM-A stated P1 was sent to the hospital and admitted with diagnosis of acute respiratory failure due to trach dislodgment and returned home on 7/22/24. During an interview on 7/31/24 at 2:22 p.m., RN-A stated she received 30 minutes of orientation from LPN-A prior to working on the night of the incident. RN-A stated P1 was more difficult than she had expected, she was not trained to the home, did not know where things were. It was reported P1 had increased secretions during the day. RN-A suctioned him and connected him to his ventilator around 11:00 p.m. Around 2:00 a.m. she turned P1 to change him, and his oxygen saturations went down to approximately 88% and the alarms on his machines started to go off. RN-A stated that was when she started to trouble shoot to try to figure out what to do to stop the alarms and yelled for P1’s family members. RN-A stated just prior to yelling for the family members she had started to Ambu bag P1, his oxygen saturations went up and then right back down, when the family member entered P1’s room things went crazy, and stated she didn’t know what the oxygen saturations were or if P1 had a heart rate due to the positioning of P1 and started chest compressions. RN-A stated she then told a family member to call 911. RN-A stated she did not know where the emergency supplies were at in P1’s home and did not send the emergency supply bag with P1 when P1 left with the paramedics. During an interview on 7/31/24 at 6:01 p.m., LPN-A stated she provided training to RN-A before she left her shift on 7/18/24, in the evening around 5:15 p.m. LPN-A stated she orientated RN-A for about 45 minutes and RN-A asked some questions about P1’s ventilator and trach. LPN-A stated she asked RN-A how comfortable she felt with trach/vents and RN-A told her she felt fine. LPN-A stated RN-A called her a couple of times during her shift asking questions about ventilator connections. On 7/19/24 when the paramedics arrived the family member put LPN-A on the phone as RN-A could not provide them the needed information. RN-A did not want to provide the paramedics with P1’s medical record at the home, which I told the paramedics to take. RN-A did not sign out any of the treatments during her shift for P1. During an interview on 7/31/24 at 7:34 p.m., family member (FM)-B stated RN-A woke her up at 2:45 a.m. on 7/19/24 yelling by knocking on the bedroom door and when FM-B walked into P1’s room, P1 was purple in color. FM-B had never seen P1 like that, and all the alarms of the ventilator, oxygen tank were going off. FM-B stated she saw the oxygen saturation rate on P1’s machine was at 20% and told RN-A she needed to Ambu bag P1 and after RN-A Ambu bagged P1, RN-A did chest compressions at 3:00 a.m. RN-A told me to call 911. FM-B stated at that point she thought his oxygen saturation rate was at 10%. During an interview on 8/06/24 at 9:15 a.m., the respiratory therapist (RT) from Pediatric Home Service (PHS) stated she was able to get readings from P1’s ventilator from 7/18/24 to 7/19/24. RT stated review of the readings indicated on 7/18/24 at 11:36 p.m., P1’s ventilator was turned on and problems started to appear at 2:42 a.m. on 7/19/24, and persist from 2:42 a.m. to 3:10 a.m., when the ventilator was turned off. The RT stated there was nine times the ventilator alarm was also placed on pause (silencing the alarm) and the RT stated they teach in their class to never silence the alarm during an emergency since it takes time away from a patient and the alarms are also to alert other family members in the home to assist for help. In addition, the RT stated RN-A should have called 911 or a family member immediately after using the Ambu-bag since that would be a sign the patient is losing oxygen to the brain. The RT stated from the readings noted an issue with low minute ventilation at 2:42 a.m. which means there was an airway leak either from the trach not being in place or the patients position and then the nurse needs to trouble shoot from repositioning and then check for trach placement. The low minute ventilation alarm continued to go on until the ventilator was shut off at 3:10 a.m. The RT further stated she was unable to retrieve the oxygen saturation readings since it was too late once the machine was picked up since the data can only be retrieved up to 96 hours after an incident. During an interview on 8/06/24 at 10:15 a.m., CM-A stated RN-A has been removed from providing care with patients with Vent/Trach patients after the incident occurred with P1. In addition, the agency also has made a list of nurses that are only qualified to provide care for P1 in the future if P1 would need a nurse. CM-A stated they should be documenting treatments at the time they are being completed. Facility policy revised 8/13/2021, indicated Preparing for Emergencies each client with a tracheostomy tube is required to have an Emergency Airway Bag and a Go Bag, which is to be used for the storage for emergency airway equipment. It contains all essential equipment for an emergency tracheostomy change and provides for a consistent setup for every client with a tracheostomy. The policy further indicated during Handling Client Emergency, if the client’s condition deteriorates, and they need immediate attention, the employee, client, or caregiver should proceed in the following manner: -Call emergency squad (911 in most areas) -Call the office and inform them of the situation; the office manage will them call the client’s health care provider and family members if applicable; and stay with the client until help arrives.”