Failure to Provide Complete and Sterile Tracheostomy Care
Penalty
Summary
The facility failed to provide complete and appropriate tracheostomy care for a resident with chronic respiratory failure and a tracheostomy. The resident was observed with wet, soiled tracheostomy ties and collar, yellow, green, and brown drainage, and a foul odor, as well as a red spotted rash on the neck and upper chest. There was no drainage sponge under the tracheostomy, and the resident was seen cleaning the area himself using the same gauze pad multiple times, without being offered hand hygiene. The LPN assisting the resident did not consistently perform hand hygiene between glove changes, touched her hair with gloved hands, and did not follow sterile technique as outlined in the facility's tracheostomy care policy. The resident, who is cognitively intact but dependent on staff for activities of daily living, reported that he has been caring for his tracheostomy for several years and prefers to do it himself, although staff will assist if asked. The DON was unaware that the resident was performing his own tracheostomy care and acknowledged that the resident should have been educated and monitored to ensure proper technique. The facility's policy requires daily cleaning of the inner cannula, changing of tracheostomy ties and collar when soiled, and strict adherence to sterile procedures, which were not followed in this instance.