Failure to Maintain Sterile Technique in Tracheostomy Care
Penalty
Summary
A deficiency was identified when a resident with a tracheostomy did not receive respiratory care consistent with professional standards of practice. The resident, who required oxygen via tracheostomy and was observed to have shortness of breath with audible breath sounds, was under the care of staff trained in tracheostomy care and suctioning. Documentation showed that suctioning was performed by a licensed practical nurse during the night shift, and the facility's policy required the use of sterile technique for this procedure. However, a used suction catheter was observed left on the resident's bedside table, indicating a lapse in infection control and sterile technique. The nurse responsible for the care acknowledged providing suctioning and confirmed that the procedure should be sterile, as outlined in facility policy. The presence of the dirty catheter at the bedside and its subsequent removal only after being noticed by surveyors demonstrated a failure to maintain proper infection control practices during respiratory care for the resident.