Failure to Maintain Sterile Technique During Tracheostomy Care
Penalty
Summary
A deficiency was identified when a registered nurse (RN) failed to maintain sterile technique while providing tracheostomy care to a resident. During the observed procedure, the RN placed the sterile field on a side table and positioned non-sterile items, including a box of normal saline and gauze, on top of the sterile field. Each time the RN reached for these supplies, the non-sterile part of her arms crossed over the sterile field, resulting in a break of sterile technique. The RN confirmed during an interview that she was unaware she was breaking the sterile field, despite having received training in tracheostomy care and infection control within the year. The resident involved had significant medical needs, including anoxic brain damage, contractures, aphasia, and dysphagia, and was non-verbal and dependent on staff for all activities of daily living. The resident's care plan and physician orders required sterile tracheostomy care to prevent infection. Facility policy and professional standards specify the maintenance of a sterile field during such procedures. Despite annual competency checks indicating the RN was qualified, the observed failure to maintain sterility during tracheostomy care constituted a deficiency in ensuring staff competency and adherence to professional standards.