Failure to Maintain Sterile Technique During Tracheostomy Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically in the provision of tracheostomy care for a resident on enhanced barrier precautions due to ESBL colonization. During an observed tracheostomy care procedure, a nurse did not set up all necessary supplies beforehand and used a previously opened, non-sterile saline bottle instead of sterile saline as required by policy. The nurse also broke sterile technique by reaching into the resident's bedside table with sterile gloves to retrieve additional supplies and did not stop the procedure after contaminating the sterile field. The resident involved had multiple complex medical conditions, including a tracheostomy, hemiplegia, stroke, dysphagia, and depression, and required assistance with all activities of daily living. The care plan indicated the resident was at high risk for further cognitive impairment and psychosocial issues. The resident was on enhanced barrier precautions due to ESBL colonization and required regular tracheostomy care and suctioning every nursing shift. Interviews with facility staff revealed gaps in adherence to sterile technique and inconsistencies in training and competency checks. The nurse involved acknowledged the breach in sterile field and the failure to restart the procedure with new supplies. The DON and a respiratory consultant both indicated that tracheostomy care training was provided, but there was a lack of familiarity with current facility policies and procedures. Review of the facility's tracheostomy care and suctioning policies confirmed the requirement for sterile technique and the use of sterile supplies.