HospitalInspections.org

Based on document review and interview it was determined, in 1 of 5 (Pt #1) patients with tracheotomies, the Hospital failed to ensure adherence to policies and procedures regarding trach care; thus placing all trach patients at risk for infection.

Findings include,

1. Pt#1 was a 51 year old female admitted on 1/28/14 with a diagnosis of intracranial hemorrhage. Pt #1's clinical record included that on 2/4/14 Pt #1 had a tracheostomy placed. Pt#1 was subsequently admitted to the rehabilitation unit (Bowman Pavilion) on 3/6/14 under the care of MD#1 (Attending Physician). Pt #1's clinical record contained a physician's order dated 3/20/14 at 7:39 AM that included a consult to general surgery to downsize the tracheostomy. On 3/21/14 Pt #1's tracheostomy was downsized to a Shiley 5XLT.

Pt #1's clinical record contained MD#3's (Resident of Physical Medicine and Rehabilitation) progress note date 3/22/14 at 11:41 PM that documented, "The patient's tracheostomy was downsized from 6 Shiley XLT to 5 Shiley XLT cuffless on Friday by surgery service II. The 5-0 size needed to be specially ordered by the service. Unfortunately our central supply does not have size 5XLT inner cannulas."

Pt #1's clinical record contained tracheostomy care flow-sheets dated 3/20/14-3/27/14 including 3/21/14, the day the tracheostomy was downsized to a Shiley 5 XLT). The clinical record included that from 3/22/14-3/25/14 the inner cannula was cleaned and not replaced every 12 hours as required.

2. Hospital policy entitled, "Tracheostomy: General Care and Emergency Care," (Approved date 10/30/12) included, "...10. The inner cannula of the double cannula tracheostomy tube is either cleaned or replaced at least every 12 hours and prn (as needed) ...General Tracheostomy Care: RN/LPN: 8. Perform care of the inner cannula: disposable versus non disposable. 9. Disposable: Discard disposable used inner cannula in the appropriate container ....insert inner cannula into outer ..."

3. Manufacturer recommendations entitled, "Convidien Shiley Tracheostomy Tube," (2011) required, "This product cannot be adequately cleaned and/or sterilized by the user in order to facilitate safe reuse, and is therefore intended for single use. Attempts to clean or sterilize these devices may result in bio-incompatibility, infection or product failure to the patient. Warning: The Shiley Inner Cannula XLT ....are disposable medical devices and are designed for single use and should not be cleaned or reused."

4. On 4/30/14 at approximately 3:00 PM the Accreditation Manager stated that the nurses on the rehab unit were not following Hospital guidelines when caring for the patient's trach.