Failure to Follow Infection Control and Emergency Equipment Protocols for Tracheostomy Care
Penalty
Summary
The facility failed to follow infection control practices and ensure the availability of emergency equipment for residents with tracheostomy and oxygen care. For one resident, staff were unable to locate a replacement tracheostomy tube at the bedside, and the oxygen tubing was found on the floor, disconnected from the trach collar, resulting in the resident not receiving oxygen at the time of observation. Staff placed the contaminated tubing back onto the resident's trach, and no replacement tubing was available in the room. Emergency trach equipment was eventually found on a shelf behind the phone, not at the head of the bed as required. Another resident was observed without emergency trach equipment at the head of the bed, and the oxygen tubing was kinked, potentially obstructing oxygen flow. The distilled water for oxygen use and the suction canister were not dated, and the canister contained discolored secretions. In a third resident's room, after the resident had been transferred to the hospital, the suction canister with secretions and the opened distilled water were both undated. In a fourth resident's room, oxygen tubing was found stored in a basin on the floor, and there was no storage bag available for the tubing, contrary to facility policy. Medical record reviews revealed that care plans for residents with tracheostomies lacked documentation of trach size, and oxygen orders were incomplete or missing key details such as route and duration. Facility policies required that replacement trach tubes be readily available and that oxygen delivery devices be kept covered and changed if contaminated, but these practices were not followed for the residents reviewed.