Failure to Maintain Sterile Technique During Tracheostomy Care
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy did not receive respiratory care in accordance with professional standards. The resident, who was nonverbal and required extensive assistance with all activities of daily living, had diagnoses including anoxic brain damage, contractures, aphasia, and dysphagia. Physician orders and the care plan specified that sterile tracheostomy care was to be provided every shift to prevent infection. During an observation, an RN performed tracheostomy care but broke sterile technique by placing non-sterile items on the sterile field and repeatedly crossing the sterile field with non-sterile parts of her arms while reaching for supplies. The RN acknowledged breaking the sterile field but was unaware of doing so at the time, despite having received training in tracheostomy care and infection control within the year. The DON confirmed that sterile technique was required for tracheostomy care and that the RN's actions constituted a breach of sterile field. Facility policy and professional standards reviewed also emphasized the importance of maintaining a sterile field during such procedures.