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Based on staff interview, medical record review, and review of the endotracheal suctioning policy and procedure and the Mosby's Skills guidelines utilized by the facility, it was determined the facility failed to ensure respiratory care staff provided appropriate suctioning technique. This affected one patient (Patient #1) out of ten medical records reviewed. The active census at the time of the survey was 412.

Findings include:
1. Patient #1 was admitted to the facility on 03/20/14 for an electroencephalography (EEG) electrical recording of brain activity after the mother reported an increase in seizure like activity. Patient #1 has a complex medical history of congenital aqueduct stenosis, polyhraminos, severe hydrocephalus, epilepsy, subglottic stenosis and tracheostomy. Patient #1 experienced a cardiopulmonary arrest after acutely dropping his/her heartrate in the early morning of 3/21/14 that required chest compressions and a transfer to the pediatric intensive care unit with ventilator support. Patient #1 was eventually transferred back to neurology service and discharged home on 04/01/14 per review of documentation on the incident report dated 03/20/14.
Review of a physician consult note signed by Staff L dated 03/22/14 at 12:49 PM stated Patient #1 had cardiopulmonary arrest on 03/21/14 likely secondary to a mucous plug of the tracheostomy and continues on ventilator support.
Review of nursing note dated 03/21/14, timed at 5:36 AM, signed by Staff J states RN(registered nurse) in Patient #1's room at 3:52 AM flushing intravenous line, RN left room and RN heard code called at approximately 3:55 AM with RT (respiratory therapist) at bedside.

Review of Respiratory Therapy documentation signed by Staff I on 03/21/14, timed at 5:48 AM, states Staff I arrived at patient's bedside around 3:50 AM to assess patient. Patient #1 was with the nurse and the patient care assistant. Patient #1 appeared to be visibly upset and was audibly congested with secretions noted in the patient's mouth. Staff I suctioned a small amount of thick cloudy secretions via tracheostomy and orally. Staff I documented he/she turned around to obtain new suction equipment and pulse oximeter and the heart rate dropped and a code blue was called. Staff I provided respirations via manual bag and the registered nurse did chest compressions until the code team arrived. Review of the Cardiopulmonary resuscitation record dated 3/21/14 revealed the cardiopulmonary arrest event was recognized at 3:55 AM.

2. Staff A, RN Director of Accreditation, stated in an interview on 07/14/14 at 2:37 PM that endotracheal suctioning procedure is based on the Mosby's Skills guidelines. Staff E, Director of Respiratory Care, stated in interview on 07/16/14 at 1:01 PM that Mosby's Skills is used as a guideline when developing respiratory care policy and procedures and the policy and procedure training for the respiratory therapists is performed upon hire.

3. Review of the Mosby's skill guidelines revealed at Section 8 if secretions remain in the airways after two suction catheter passes, allow the patient to rest. Section 9 states use a separate catheter to perform oropharyngeal suctioning, typically using a Yankauer suction catheter. Following oropharyngeal suctioning the catheter is contaminated with bacteria present in the oral cavity, potentially gram-negative bacilli.

4. As part of EEG procedure the patient is video recorded while EEG is being completed. The medical record included a video recording on DVD of the patient and staff at bedside during the test. The video revealed Staff I, respiratory therapist, suctioned the oral cavity of Patient #1 and then provided endotracheal suctioning with the same contaminated catheter. Staff C confirmed based on policy and procedure, Staff I, violated policy by suctioning oral cavity and then trachea. This was confirmed with Staff C, Unit Director, on 07/15/14 at 3:17 PM.

5. Review of the CCHMC Resource clinical practice policy I-207: Tracheotomy Tube Suctioning, states the length of suctioning should be less than five seconds.

6. Per review of the video DVD, Staff I suctioned approximately 4-5 times at different intervals prior to the code blue. Review of the video DVD revealed that several suction passes were seven to twelve seconds in length. This finding was confirmed with Staff E on 07/16/14 at 2:15 PM. Staff E also confirmed as of 07/16/14, Staff I had not received any additional training on the clinical practice guidelines for endotracheal suctioning.