Health inspection·April 23, 2023

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences for 1 Resident (Resident #1) reviewed for tracheostomy care. Residents Affected - Few 1. The facility failed to maintain sterile procedure during tracheostomy care for Resident #1. 2. The facility failed to provide disposable inner cannulas for daily cannula changes as physician ordered for Resident #1 These deficient practices could place residents with tracheostomies at risk of respiratory infection, complications, and hospitalization Findings included: Record review of Resident #1's face sheet revealed a [AGE] year-old male, admitted to the facility on [DATE] and originally admitted on [DATE]. His diagnoses included acute kidney failure, UTI, muscle weakness, diabetes (high sugar levels for prolonged periods), epilepsy (neurological disorder causing seizures), HTN, GERD, intracranial injury, tracheostomy status (opening into the windpipe allowing air to flow in and out) and gastrostomy status (feeding tube through hole in the stomach). Record review of Resident #1's quarterly MDS (a resident assessment and care screening) dated 02/22/2023 revealed he had adequate ability to hear and had no speech. The staff assessment for mental status revealed Resident #1 had severely impaired cognitive skills for decision making (never/rarely made decisions). He required extensive to total assistance with all ADLs. The active diagnosis section revealed he had traumatic brain injury. He required oxygen, suctioning and tracheostomy care. Record review of Resident #1's physician order dated 02/16/2023 at 11:23AM revealed an order to change the disposable inner cannula #8 daily and PRN. Record review of Resident #1's April 2023 MAR/TAR, downloaded from the electronic health records on 04/23/2023 at 5:05PM, revealed the disposable inner cannula was documented as being changed daily on day shift between 6:00AM and 2:00PM. During an observation and interview, on 04/23/2023 at 3:45PM, LVN A stated she began working at the facility in July of 2022. LVN A checked Resident #1's room for disposable inner cannulas. Observed that there were no replacement inner cannulas with the other respiratory supplies. She stated the Page 1 of 3 675744 675744 04/23/2023 Friendship Haven Healthcare and Rehabilitation Cen 1500 Sunset Dr Friendswood, TX 77546

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few cannulas were supplied by the RT and she was told they were on back order. She stated she was instructed by her supervisor to clean the existing cannula until replacements arrived. She stated she only worked weekends. She stated this was the first time she had not seen a supply of replacement cannulas and Resident #1 was the only resident with a tracheostomy. LVN A stated she did not know how long Resident #1's inner cannula was being reused. She stated she was uncomfortable cleaning a disposable cannula and therefore she did not do this when she did the trach care during the morning (04/23/2023). LVN A disinfected the bedside table and checked Resident #1's oxygen saturation rate which was 96% and his pulse was 79. The resident's eyes were open and was in no distress. LVN A raised the HOB higher and then washed her hands. LVN A opened three sterile trach kits. LVN A stated she will be using the gloves in the kits because she did not have a supply of clean gloves on hand. LVN A removed the sterile drape from one of the kits and draped it over the table then emptied contents of kit onto sterile drape. She then opened the sterile gloves package and put them on then moved the plastic container from the non-sterile area on the bedside table onto the sterile field. LVN A opened the NS plastic ampules that came with the kit and poured it into the plastic container. Resident #1's family was present and assisted LVN A by opening more NS plastic ampules and pouring the liquid into the sterile plastic container. LVN A reached over the sterile field for the suction catheter. LVN A connected the sterile suction catheter and used her left hand as dominant hand then tested the suction by drawing up normal saline. LVN A stated her left hand will be the dominant hand. Resident #1 coughed up thick, brown secretions which landed onto the split gauze. LVN A made three passes to suction secretions. The left sterile gloved hand used to suction, touched the mist mask each time. LVN A removed the inner cannula and then placed into normal saline to soak. The inner cannula had a thick clot of dark colored secretion stuck inside. LVN A removed the soiled gauze dressing, removed gloves, and tossed into the trash bin. LVN A reached over sterile field to get another pair of sterile gloves from another kit and put on the gloves then cleaned and dried the cannula with a sterile gauze. LVN A replaced the clean inner cannula into the resident's tracheostomy. LVN A cleaned the skin beneath the trach flange using cotton swabs dipped in normal saline then applied sterile split gauze. LVN A checked Resident #1's oxygen saturation rate and it was at 96%. LVN A cleaned up then washed her hands. In an interview on 04/23/2023 at 4:30PM, LVN A stated her last in-service for tracheostomy care was last year with the RT. LVN A was asked why it was important to maintain sterility of the gloved dominant hand, she stated it was because bacteria could enter the resident's tracheostomy. She stated she was unaware that her hand touched the mask and that she reached over the sterile field. She stated it was important to not to reach over d/t cross contamination and infection control. She stated she did disinfect the table and that she did not know she had to hand hygiene between glove changes. In an interview on 04/23/2023 at 5:15PM, the DON, who started working at the facility 3 weeks ago, stated usually the DON was supposed to set up the schedule and RT would conduct the staff inservices on Tracheostomy care. The DON stated the sterile field was to prevent infection and bacterial growth. The DON stated if the nurse was reaching over the sterile field, then anything on sterile field was no longer sterile. The DON stated the nurse should have sanitized her hands between glove changes for infection control. The DON stated the disposable cannulas cannot be cleaned and then reused but she was unsure and would look for the policy and procedure. In a telephone conversation on 04/23/2023 at 5:20PM, the RT stated he just started working with the facility 3 months ago. The RT stated he did not realize how many cannulas Resident #1 would go through, and the family wanted it changed twice a day. RT stated the Portex inner cannulas were on back order and expected to arrive Monday 04/24/2023. The RT stated the inner cannulas were made from the same material as the 675744 Page 2 of 3 675744 04/23/2023 Friendship Haven Healthcare and Rehabilitation Cen 1500 Sunset Dr Friendswood, TX 77546

F 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few permanent outer cannula and can be cleaned and reused. The RT stated most places keep the same disposable inner cannula and then toss in a week. RT stated there were no health risks to re-using the inner cannula. In an interview on 04/23/2023 at 6:00PM, the DON stated she was unaware that Resident #1 did not have any more inner cannulas and that any nurse working with Resident #1 should have notified her. In an interview on 04/23/2023 at 7:00PM, the DON stated, not having inner cannula replacements for Resident #1 probably happened because the staff were used to not having a DON and managing issues themselves even though an interim from Regional was at the facility. The DON stated she reached out to the MD and found some cannulas from another facility that they could have. The DON stated she expected that the nurses should not have check marked they were changing the cannula when there were no replacements available. Record review of the facility policy for Suctioning the Lower Airway (Endotracheal (a tube inserted into the trachea through the nose or mouth), or Tracheostomy Tube), revised October 2010, read in part: .The purpose of this procedure is to remove secretions, maintain a patent airway, and prevent infection of the lower respiratory tract General Guidelines .1.b Use sterile equipment to avid widespread pulmonary and systemic infection .Steps in the Procedure .14. Apply sterile gloves. The dominant hand will remain sterile Record review of the facility policy for Handwashing/Hand hygiene, revised August 2015, read in part Policy Statement - This facility considers hand hygiene the primary means to prevent the spread of infections .Policy Interpretation and Implementation .7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .f. before donning sterile gloves .m. After removing gloves 675744 Page 3 of 3