Failure to Provide Safe and Sterile Tracheostomy Care
Penalty
Summary
A resident with a tracheostomy, impaired cognition, and multiple medical diagnoses was observed receiving tracheostomy care that did not adhere to professional standards, the resident's care plan, or facility policy. During the procedure, an LPN failed to maintain sterile technique by using her designated 'dirty' hand to adjust the resident's oxygen and then used the same hand to open a bottle of normal saline, contaminating the sterile field. The LPN then poured the saline into the tracheostomy care kit without recognizing the breach in sterility. Additionally, the LPN did not oxygenate or hyper-oxygenate the resident between suction passes, as required by evidence-based procedures, and performed three consecutive suction passes without providing rest periods or assessing the resident's respiratory tolerance. The LPN acknowledged during an interview that she broke sterile field and did not follow proper oxygenation procedures, attributing her actions to nervousness and lack of experience, having only started three weeks prior. The facility's policy and infection control procedures were not followed during the tracheostomy care, and the LPN did not set up a clean working area or barrier for the sterile procedure. Interviews with other nursing staff confirmed knowledge of the correct procedures and the importance of restarting the process if sterility is compromised.