Failure to Provide Sterile Tracheostomy Care and Suctioning
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care, including tracheostomy care and suctioning, consistent with professional standards of practice, the residents' care plans, and their preferences. Specifically, staff did not use sterile technique during tracheostomy care and suctioning for two residents with tracheostomies. Observations and video evidence showed that multiple nurses, including LVNs and the Interim DON, performed tracheostomy suctioning and care without sterile gloves or proper sterile technique. In some cases, staff did not change gloves or perform hand hygiene between procedures, and sterile supplies were reportedly unavailable at times. The facility's own policy required sterile technique for these procedures, but this was not followed. One resident, a male with tracheostomy status and dependent on staff for all ADLs, exhibited signs of respiratory distress, including abdominal retractions and audible gurgling. Despite a family member's request, an LVN refused to reassess the resident or provide tracheal suctioning, arguing with the family member and leaving the room without performing the necessary care. The resident was later found to have bacteremia and was transferred to the hospital. Another resident with anoxic brain damage and acute respiratory failure, also dependent for all ADLs and with a tracheostomy, was observed receiving tracheostomy care from an RN who contaminated her sterile gloves and continued the procedure without reapplying them, using non-sterile supplies and breaking sterile field throughout the process. This resident had a history of recurrent pneumonia and was being treated for an active infection at the time. Additionally, the facility failed to provide competency check-offs for several nurses on tracheostomy care and suctioning, and there was no evidence that all staff had been educated on the required sterile technique. Interviews with staff confirmed a lack of consistent sterile supplies and incomplete training. The facility's failures were identified through observations, interviews, record reviews, and video evidence, and were found to be inconsistent with both facility policy and professional standards of practice.