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Based on observation, record review, and interview, the facility infection control officer failed to ensure policies governing control of infections were implemented for tracheostomy care given by 2 of 2 respiratory therapists (RT) (#s 5 and 4) for 2 of 2 patients with tracheostomies (#7 and #1).

Findings include:

TX # 00191350

Patient #7

Record review on 2/19/14 of Patient #7's electronic medical record revealed he was admitted on 1/9/14 with diagnoses that included acute respiratory failure and sepsis.

Record review on 2/19/14 of Patient #7's Infectious Disease Consultation dated 1/10/14 revealed the patient was admitted from a local hospital with pneumonia that was being treated with antibiotic therapy. Sputum cultures from the hospital revealed MRSA (Methicillin Resistant Staphylococcus Aureus).

Observation and interview on 2/19/14 at 9:50 a.m. revealed RT #5 was preparing to perform tracheostomy (trach) care and suctioning for Patient #7 in ICU (Intensive Care Unit). There was a sign in the room that the patient was on droplet isolation. Interview at this time with the ICU Charge Nurse, RN #13, she said the patient had MRSA of his sputum. After placing supplies on top of the patient's bed linens, RT #5 opened the sterile suction catheter package, placed it on the bed linens and then opened the sterile package of gloves and placed it on top of the suction catheter. RT #5 took both sterile gloves in his hands and them put them on, without ensuring they were put on in a sterile manner. This contaminated the gloves. He then picked up the suction catheter and proceeded to suction Patient #7's trach. Because his gloves were contaminated, anything he did with the catheter made it contaminated also. After suctioning the patient, RT #5 removed the old split trach. dressing from the stoma and threw it in the trash can. He did not perform hand hygiene and put on a new pair of gloves before he opened a package of split trach. dressing, wet it with normal saline and began to clean around the trach. stoma. He did not wipe in one direction from the stoma out, but wiped back and forth around the stoma, cross contaminating the entire area. With the same contaminated gloves, he went to a push bottom locked cabinet, pushed the keys and tried to open the cabinet. It did not open. He then opened another split trach. dressing package that was on the bed linens and put it around the trach. stoma. With the same contaminated gloves, RT #5 performed oral care for Patient # 5's mouth. He opened a brown bottle of Chlorhexidine Gluconate and dipped the clean toothbrush in the bottle. Then he brushed the patient's teeth. After brushing the patient's teeth, he placed the toothbrush on the open package. He got a suction tip and began to suction the patient's mouth. The toothbrush fell on the floor. RT #5 picked up the toothbrush with the same gloves on, threw it in the trash and went back to providing oral care for the patient with the same contaminated gloves. He then opened a packet of moisturizing ointment and put it on the patients lips and in his mouth. RT #5 then went back to the locked cabinet, pushed the numbered buttons and opened the door. He removed a disposable inner cannula and replaced it for the old one, with the same original contaminated gloves. He then picked up the trash from the bed lines, threw them in the trash and removed his gloves. Without performing hand hygiene, he replaced the lid to the contaminated Chlorhexidine Gluconate bottle and put it in the locked cabinet. Then he went into the bathroom and washed his hand.

Interview on 2/19/14 at 10:00 a.m. with RT #5, he was asked if trach. care was to be done in a sterile manner. He said it was. He was asked if he had put on the gloves in a way to ensure they were kept sterile. He said he felt he had done that. When he was informed that he was seen picking them up together and putting them on, he then agreed that was not done in a sterile manner. He was asked about changing his gloves and performing hand hygiene. He said he put a pair of gloves on and did everything with the same pair of gloves. When he was asked about picking up the toothbrush on the floor and putting the brown bottle back in the cabinet, he agreed he had cross contaminated items. He said he did not do a skills check on trach. care annually. He said he had worked at the facility for three years.

Interview on 2/19/14 at 10:25 a.m. with the Director of Respiratory Therapy #6, he was informed how RT #5 had wet a split trach. dressing and wiped around the stoma. He was asked if RT #5 should have used peroxide. He said they had a trach. care kit that contained peroxide and RT #5 should have used it. He said that peroxide was damaging to tissue and that using only normal saline was alright to do. He was asked if his staff were trained to perform hand hygiene and change gloves after removing a dirty dressing and before cleaning and replacing a new dressing. He said they did not change their gloves. He had a copy of the facility's policy and procedure for providing trach. care and said that the policy stated they should perform hand hygiene and change their gloves from dirty to clean. When he was informed of all the areas that had been cross contaminated, he agreed the procedure performed by RT #5 was not acceptable. The Director was asked if he provided in-services to his staff on trach. care. He said he had not provided any in-services. He said they did a check off during department orientation, but the procedure was not gone over again.

Interview on 2/19/14 at 2:40 p.m. with RT Supervisor #14, she said the Respiratory Therapists were responsible for putting the therapy orders in the computer.

Record review on 2/19/14 of Patient #7's respiratory therapy orders dated 1/9/14 revealed the following:
Trach. care - hydrogen peroxide 50% every 12 hours

During an interview on 2/19/14 at 2:10 p.m. with Infection Control Nurse, RN #12, she was asked if the infection control program had any connection to respiratory therapy. She said not currently at this time. She said the facility had a Nurse Practitioner that worked in ICU who was currently working with the nurses on identified infection control concerns. RN #12 said she had only been in her position since 10/2013 and was concentrating on nursing issues.


23032

Patient # 1:

Record review of Patient # 1 ' s History & Physical Exam, dated 10-14-13, revealed he was a 72 year old male patient admitted to the facility on 10-14-13 for management of ventilatory support. Patient # 1 had a recent history of cardiopulmonary arrest and cerebral vascular accident (CVA). He was in a " vegetative state and remained encephalopathic. " Patient # 1 had a recent tracheostomy and a percutaneous endoscopic gastrostomy (PEG) tube inserted.

Observation on 02-19-14 at 10:10 a.m. of Respiratory Therapist (RT) /ID # 4 revealed she prepared to suction and perform tracheostomy (trach) care on Patient # 1. RT / ID # 4 opened the outer package of a pair of sterile gloves and laid the paper-covered gloves directly on the bed sheet of Patient # 1. She failed to clean a surface to use to set up a sterile field, and used the paper from the sterile gloves throughout the suctioning procedure. RT/ID # 4 donned the sterile gloves on top of a pair of exam gloves.

Further observation revealed RT / ID # 4 failed to auscultate Patient # 1 ' s lungs or measure the oxygen saturation level prior to suctioning. RT / ID # 4 suctioned Patient # 1 three (3) times. She appropriately hyper-oxygenated Patient # 1 ' s lungs with ambu bag and instilled normal saline into the trach prior to suctioning. RT/ID # 4 stated her " right hand was sterile for the suctioning and the left hand was contaminated. "

After the first time she introduced the disposable suction catheter down into the trach; the catheter then draped across her right forearm. RT /ID #4 was stopped before introducing the catheter again. She stated: " It is OK because I am not putting that portion down into the patient, just this end. "

After the suctioning was completed, RT / ID # 4 removed her sterile gloves and left the exam gloves on. She did not perform any hand hygiene. The drain sponge surrounding Patient # 1 ' s trach had copious amounts of thick yellow secretions on it. RT/ID # 4 removed this drain sponge. While wearing the same contaminated gloves, she went to a bedside table and went through boxes of supplies on the top of the table and also touched supplies contained in 2 of the table drawers. RT/ID # 4 stated she was looking for a bottle of sterile saline. Wearing the same contaminated gloves; she cleansed the area around Patient # 1 ' s trach. She donned new exam gloves with no hand hygiene in between, and proceeded to replace the disposable trach with a new one.

Interview on 02-19-14 with RT/ID # 4 immediately following the suctioning and trach care of Patient # 1, she acknowledged that she should have removed her contaminated gloves and sanitized her hands prior to touching the clean supplies. In addition, RT/ID # 4 said she " should have listened to the patient ' s breath sounds prior to suctioning. "

Interview on 02-19-14 at 11:45 a.m. with Director of Respiratory Therapy ID # 6 he stated that the bedside table should be cleaned and used to set up the supplies for trach suctioning and care. The RT Director/ID # 6 went on to say that prior to suctioning, the patient ' s heart rate, respiratory rate and lung sounds should be assessed. He further stated that hand hygiene should be performed between each glove change.

Record review on 02-19-14 of the personnel files of RT/ ID # 4 and RT /ID # 5 revealed they each had documented competencies (initial and annual) for " Endotracheal Suctioning (Closed System). "Continued interview with RT Director /ID # 6 on 02-19-14 at 11:45 a.m. he acknowledged the RTs did not have documented competencies in endotracheal or trach suctioning using an open system.

Review of facility policy titled " Tracheostomy and Endotracheal Tube Open Suctioning, " dated 12/08, read: " ...suctioning will be performed using sterile technique... Procedure: 1. Wash hands ...3. Prepare equipment: D. Don sterile gloves. ..the hand that passes the catheter must remain sterile ...monitor for complications: slow pulse, irregular pulse, skin color ...11. Protect the sterility of the suction catheter if several passes are to be made during the suctioning procedure. If at any time catheter is contaminated, discard the catheter and gloves and start over ... "

Review of facility policy titled " Tracheostomy Care, " dated 10/08, read: " ...2. Wash hands and don proper PPE ...5. Mix 1/3 peroxide and 2/3 sterile water or saline in container. 6. Remove soiled dressing and inspect site. 7. Remove soiled gloves, perform hand hygiene and don clean gloves ... "

Review of facility policy titled " Hand Hygiene, ' dated 09/1997, read: " ...Hand hygiene will be performed as follows: ...F. After situations during which microbial contamination of the hands is likely to occur ...J. Before donning and after removal of gloves..."