Failure to Maintain Emergency Tracheostomy Equipment and Sterile Technique
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident with a tracheostomy by not ensuring that required emergency tracheostomy equipment, specifically an Ambu bag, was kept at the bedside as ordered and as required by facility policy. Observations revealed that while spare trach tubes and an obturator were present at the bedside, the Ambu bag was missing from the resident's room and could not be located by nursing staff on the crash cart. The Director of Nursing (DON) was also unaware of the facility's trach policy and confirmed the absence of the Ambu bag at the bedside after searching the room and surrounding areas. The Ambu bag was eventually found inside the crash cart, which was located 143 feet away from the resident's room, and staff were unable to immediately locate it when needed. Additionally, the facility failed to ensure proper infection-control practices during tracheostomy care for the resident. During an observed tracheostomy care procedure, a nurse contaminated her sterile gloves by holding the resident's hands and moving non-sterile items, but did not change gloves or reestablish sterility before continuing the procedure. The nurse proceeded to complete the tracheostomy care, including cleaning the stoma site and changing the inner cannula, while wearing contaminated gloves. The nurse reported having received training from another nurse on the floor and had shadowed for several days prior to performing tracheostomy care independently. Interviews with the Medical Director and Staff Development Coordinator confirmed concerns regarding the lack of sterile technique and the adequacy of staff training. The Staff Development Coordinator stated that new nurses were trained by more experienced floor nurses and received annual refresher training, but did not follow up to ensure correct training unless a deficiency was brought to her attention. The DON, who was new to the facility, acknowledged the importance of following proper protocol but was not familiar with the exact policy.