HospitalInspections.org

Based on observation, record review, policy review, document review, and interviews, the hospital failed to ensure staff followed Standard Precautions and Hand Hygiene policy regarding hand hygiene and tracheostomy care for 1 of 6 patients (Patient 5). This deficient practice has the potential to placed patients at risk for contracting a hospital acquired infection.

Findings Include:

Review of the facility policy titled; "Standard Precautions" revised 10/2020 showed:

Introduction - Standard Precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection in hospitals. ...This set of precautions, the focus has evolved from protecting the healthcare worker to protecting both the worker and the patient. The components of Standard Precautions include Hand Hygiene, Use of personal protective equipment (PPE), safe injection practices, respiratory hygiene - cough Etiquette, use of masks for any procedure involving spinal punctures or spinal injections.

Policy

A. The Choice of PPE is based upon the risk of exposure to body fluids. The following general principles apply:

... 2.) For procedures where respiratory secretions can contaminate the practitioner (suctioning (except in line), tracheostomy care, intubation, tracheostomy changes to face and eye protection is required.

B. Standard Precautions will not supplant the other categories of isolation precautions, but rather provide a commonsense approach for the handling of body fluids, especially blood and respiratory secretions.

C. Standard Precautions apply to blood, all body fluids, secretions, and excretions regardless of whether they contain visible blood, non-intact skin and mucous membranes.

D. Hand Hygiene per policy is required before and after every patient interaction even when gloves are used. (See hand hygiene policy).

Guideline related to PPE and Safe Work Habits

...F. Patient Care Equipment:

1. Patient care equipment known to be contaminated with infective material should be cleaned with a disinfectant- germicidal solution at the point of use or bagged in clear bags and labeled Biohazard to alert decontamination staff. All equipment found in the dirty utility room will be considered contaminated and will be cleaned appropriately by staff before storage in the clean equipment room.

2. Equipment not contaminated poses no threat and needs no special handling. Articles dropped on the floor will be disinfected and discarded.

Review of Facility Policy titled; "Hand Hygiene" revised 07/2021 showed:

Introduction - Effective Hand Hygiene is considered the basis for an effective Infection Control Program.

A. How
1. There are two methods of hand hygiene: Soap (Detergent) and water and an alcohol-based hand rub.

B. When
...2. Before and after every patient contact.
3. Between patient care activities within same episode of care.
4. When moving from high contamination patient care activities to cleaner activities/if moving from a contaminated body sites to a less contaminated body site (peri care to trach care)...
...9. Between glove changes and after removing gloves after any contact with body fluids, dressings, and patient linen.
10. Before any patient procedure or medication administration.
11. Before going into a patient room and before leaving a patient room.

Patient 5

Review of Patient 5's medical record showed a 75-year-old male admitted on 10/25/22 with an admitting diagnosis of Acute hypoxemic (not enough oxygen in your blood), hypercapnic (too much carbon dioxide in your blood) respiratory failure. Following a tractor accident (08/2022) that required rib plating (surgical procedure using titanium plates and screws to stabilize broken ribs) for multiple rib fractures. Past Medical History is Significant for hypertension (blood pressure is higher than normal), type 2 diabetes mellitus (impairment in the way the body regulates and use sugar as a fuel), psoriatic arthritis (chronic skin and nail disease), hypothyroidism (doesn't make enough thyroid hormone), and benign prostatic hypertrophy (enlarged prostate (part of the male reproductive system) gland). Recent multifocal (different spots of the lung) pneumonia (infection of the lungs) and septic shock (condition that occurs when a body wide infection leads to dangerously low blood pressure). Past Surgical History is significant for tracheostomy (incision in the windpipe made to relieve an obstruction to breathing) placement, Percutaneous endoscopic gastrostomy (PEG) tube placement (placement of a feeding tube through the skin and the stomach wall).

Family teaching included training on the cleaning of his tracheostomy and suctioning.

During an observation on 02/07/23 at 10:39 AM of Patient 5/ family teaching showed Staff E, Respiratory Therapist (RT) provided education to Patient 5 and his spouse and daughter regarding tracheostomy care. Staff E RT disconnected tubing from the ventilator, the tubing dropped and came into contact with the floor. Staff E placed the tubing back on the ventilator without replacing the tubing. Staff E RT failed to use hand sanitizer prior to donning (putting on) gloves when entering the room on two occasions. Staff E failed to complete glove change following replacement of inner cannula, heat moisture exchange (HME) (help to reduce mucus production and coughing by humidifying and filtering the air) unit, and gauze surrounding tracheostomy.

During an interview on 02/08/23 at 10:40 AM, Staff E, RT stated that the use proper hand hygiene techniques is required during patient care. Staff E RT stated that contact with anything other than the patient such as soiled materials, blood, and tracheostomy changes require donning/doffing (putting on/taking off) of gloves and proper hand hygiene. Staff E RT stated that anytime a ventilator component such as the Ballard (multi access port closed Suction System) or HME comes in contact with a soiled surface, the component would be discarded. This included components falling to the floor.

During an interview on 02/08/23 at 11:20 AM, Staff K, RT Supervisor stated that ventilator components such as inspiratory/expiratory tubing that touch the floor are to be discarded. In addition, staff are required to complete hand hygiene after touching an inner cannula, "dirty" gauze dressing, or other "dirty" materials.