HospitalInspections.org

Based on medical record review, interviews, review of policy and procedure and review of an occurrence report, respiratory staff failed to maintain additional respiratory equipment in the room of Patient Identifier (PI) # 1, a patient on a ventilator, for utilization during an urgent situation on 2/13/14. As a result of this deficient practice, the inner cannula was removed, retrieved from the trash can, cleaned and reinserted because the replacement cannula was the incorrect size. A new disposable cannula was not available for immediate use after PI # 1's current inner cannula was removed on 2/13/14 because the wrong size cannula was taken to PI # 1's room and there were no additional cannulas at the bedside. This affected one of ten sampled patients.

Findings include:

PI # 1 was admitted to the hospital on 11/14/13 with a trach ventilator and a diagnosis of Respiratory Failure. PI # 1's Medical History includes COPD (Chronic Obstructive Pulmonary Disease), Aspiration Pneumonia, Chronic Kidney Disease, Diastolic Congestive Heart Failure and Pulmonary Hypertension.


A review of the Occurrence Report dated 2/13/14 reveals:
Date of Event: 2/13/14
Shift: 7AM to 7PM
Location: Patient Room (PI # 1)
Comments: During trach (tracheostomy - a curved tube that is inserted into a stoma (a hole made in the neck and windpipe/ trachea) change, family threw away trach (inner cannula - a hollow piece of tubing that fits inside the outer cannula and is removed for cleaning or replaced if disposable) into garbage can before RT (Respiratory Therapist) could determine that new inner cannula did not fit.
Treatment: Normal procedure was not followed.
Intervention and Follow-up: "To prevent deterioration of patient, employee had daughter retrieve inner cannula cleaned and replaced until the correct inner cannula was obtained...New inner cannula was inserted."
Reviewed by Director Clinical Services: 2/14/14 Administrator: 3/1/14

During an interview on 4/9/14 at 3:15 PM, Employee Identifier (EI) # 1, Respiratory Therapy Director, said a staff Respiratory Therapist (RT) went to PI # 1's room to change the inner cannula that is disposable. PI # 1 had a size 6 cannula, but the therapist inadvertently took a size 7 to the room. The RT removed the size 6 cannula from PI # 1's tracheostomy and PI # 1's family member reportedly discarded the cannula in the trash. The therapist was unable to insert the new inner cannula because it was the wrong size. The old cannula had to be reinserted. According to the Director, it is common practice when changing cannulas to keep the inner cannula that is removed until it is certain the new cannula can be inserted. According to the Director, the therapist had no choice but to reuse the old cannula that had been discarded. The situation was urgent and the therapist could not leave the bedside. The Director stated a ventilator cannot be maintained without an inner cannula. A new size six inner cannula was inserted after the incident. The Director said he taped a size six cannula to the wall above the head of PI # 1's bed for use in an emergency.

During a telephone interview on 4/14/14 at 11:00 AM, the Administrator / Employee Identifier (EI) # 2, stated the hospital does not have a policy and procedure related to care of disposable inner cannulas.

During the interview on 4/14/14 at 11:00 AM, the Respiratory Director (EI # 1), was placed on speaker phone by the Administrator (EI # 2). The Respiratory Director stated all patients with ventilators have additional respiratory supplies in their rooms including cannulas. The supplies are stored in the bedside table.

During an interview on 4/16/14 at 9:05 AM the Vice President of Clinical Services, EI # 3, stated she is not aware if additional inner cannulas are kept in the rooms of patients with ventilators. According to the Vice President, a policy will be developed to address the use of disposable inner cannulas and it will also include maintaining an inner cannula and an obturator ( fits inside the tube to provide a smooth surface that guides the tracheostomy tube when it is being inserted).

A review of Policy # HD-NUR- 420.02, Tracheostomy Care and Suctioning revealed no information about the use of disposable inner cannulas.