Failure to Prevent Tracheostomy Tubing from Contacting the Floor
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to management of tracheostomy tubing. On multiple observations over two days, three residents with tracheostomies were seen with their tracheostomy tubing in contact with or resting on the floor while connected to their airway, and no staff were observed intervening at those times. One resident, admitted most recently on 1/6/2026 with an original admission date of 7/10/2020, was observed in the morning with tracheostomy tubing extending from the tracheostomy site and resting on the floor, and again the following day in an electric wheelchair with the tubing touching the floor. Another resident, admitted on 10/7/2025 with diagnoses including traumatic hemorrhage of the left cerebrum with loss of consciousness (sequela), encounter for attention to tracheostomy, and functional quadriplegia, was observed with tracheostomy tubing touching the floor while connected to the airway. A third resident, admitted on 12/23/2025 with diagnoses including traumatic subdural and subarachnoid hemorrhages with loss of consciousness (sequela) and encounter for attention to tracheostomy, was observed during routine care with tracheostomy tubing in contact with the floor. During interviews, the Infection Preventionist (RN6) acknowledged that tracheostomy tubing should not come into contact with the floor due to contamination risk, noting that the floor was considered dirty and that residents were already immunocompromised. An LPN reported that they conduct rounds three times per shift and check tracheostomy residents, including whether tubing is on the floor, and further stated that if something touches the floor, the expectation is to replace it with something clean. The Assistant Director of Nursing stated that staff are not supposed to have anything on the floor but was unable to explain how tracheostomy tubing was consistently maintained off the floor. These observations and statements demonstrated a failure to implement proper infection control measures to prevent contamination of tracheostomy equipment.
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