F0695

D

Improper Reuse of Single-Use Tracheostomy Inner Cannula

Fuquay Varina, North Carolina Survey Completed on 04-01-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide tracheostomy care consistent with professional standards of practice when a nurse cleaned and reused a single-use disposable tracheostomy inner cannula for a resident. The resident had been admitted with acute respiratory failure with hypoxia and had a physician’s order for tracheostomy care every shift and as needed, including cleaning or changing the inner cannula as applicable. The resident’s care plan identified a risk of complications related to the tracheostomy, with an intervention for tracheostomy care as ordered. Documentation on the Treatment Administration Record and nursing progress notes showed that the same nurse provided tracheostomy care on two consecutive night shifts, during which the care was documented as well tolerated.

In a later interview, the nurse stated that the resident’s tracheostomy inner cannulas were always single-use disposable types and that during one of those night shifts there were no extra inner cannulas in the resident’s room. She reported that, needing to provide tracheostomy care, she used a tracheostomy care kit with sterile gloves, sterile water, and a sterile brush to clean the disposable inner cannula and then reinserted it instead of discarding it and using a new one, acknowledging she knew this was not permitted and that reusing a disposable inner cannula could risk infection. She also stated she did not look for additional cannulas outside the resident’s room and did not have access to the supply room. The DON and Administrator later confirmed they were unaware of the incident at the time and affirmed that the facility used only disposable inner cannulas intended for single use and that they should not be cleaned and reused.