Failure to Provide Safe and Appropriate Tracheostomy and Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care to residents requiring tracheostomy care, as evidenced by multiple observed lapses in infection control and adherence to professional standards. For three residents with tracheostomies, staff did not follow proper procedures during tracheostomy and suctioning care. Specifically, a registered nurse (RN) was observed testing a yankauer suction device in an open, unlabeled, and undated container of water at the bedside prior to suctioning a resident's tracheostomy, rather than using sterile saline as required. The same RN did not monitor the resident's oxygen saturation during tracheostomy care, despite physician orders to do so, and continued with care even when the yankauer was not functioning properly. The RN also failed to perform hand hygiene at critical points, such as before donning gloves, between glove changes, and after touching potentially contaminated surfaces, and did not maintain the sterility of the field or supplies during the procedure. Observations revealed that open containers of clear liquid, which were undated and unlabeled, were present at the bedsides of multiple residents with tracheostomies. These containers were used for testing or priming suction devices, contrary to infection control protocols that require the use of sterile, single-use saline or water. Staff interviews confirmed inconsistent understanding and application of proper tracheostomy care procedures, including the use of sterile technique, hand hygiene, and the correct method for testing suction equipment. Some staff believed it was acceptable to use open water at the bedside, while others stated that only sterile saline should be used and that containers should be covered, dated, and replaced every 24 hours. Record review showed that residents had physician orders for regular tracheostomy care, suctioning, and oxygen saturation monitoring, and care plans aimed to prevent infection and maintain adequate oxygenation. However, the observed practices did not align with these orders or with the facility's own policies, which specify that tracheostomy care is a sterile procedure and require hand hygiene before and after care, as well as the use of sterile supplies. Facility in-service records indicated that no recent training on tracheostomy care had been conducted. Interviews with facility leadership, including the DON and ADON, confirmed that the observed practices did not meet facility expectations or policy requirements.