Failure to Maintain Sterile Technique During Tracheostomy Suctioning
Penalty
Summary
Nurse #5 failed to follow sterile technique while providing tracheostomy care and suctioning for Resident #38, who had a history of chronic respiratory failure, traumatic brain injury, and a tracheostomy. During the observed procedure, Nurse #5 initially washed her hands and applied clean gloves to open the sterile tracheostomy care kit. After removing the resident's oxygen tubing and discarding her gloves, she washed her hands and applied sterile gloves. However, she then picked up the unopened suction catheter container from outside the sterile field and opened it with both hands. Without re-washing her hands or applying a new sterile glove to her dominant hand, she connected the suction catheter to the tubing and proceeded to suction the resident's tracheostomy. This sequence of actions did not maintain sterile technique as required for tracheostomy suctioning. The nurse admitted to forgetting the correct procedure due to nervousness during observation. Interviews with the unit manager, Director of Nursing, and Infection Preventionist confirmed that the expected protocol was not followed, specifically regarding the maintenance of sterility during the suctioning process.