Failure to Follow Enhanced Barrier Precautions During Tracheostomy Care
Penalty
Summary
The facility failed to ensure that respiratory staff followed infection control practices during tracheostomy care for a resident with a tracheostomy. According to the facility's Enhanced Barrier Precautions (EBP) policy, staff are required to wear gowns and gloves during high-contact care activities, such as tracheostomy care, for residents with indwelling medical devices. Observation revealed that the respiratory nurse technician provided tracheostomy care to a resident who was dependent for activities of daily living and had multiple diagnoses, including respiratory failure, without wearing a gown as required by the EBP protocol. The technician wore only a mask and gloves during the procedure, despite signage on the resident's door indicating the need for both gown and gloves. Interviews with staff confirmed inconsistent understanding and implementation of the EBP requirements. The respiratory nurse technician stated that he wore a gown only for residents on contact isolation precautions, not for those on EBP, while another respiratory nurse technician and the Director of Nursing both indicated that a gown should be worn during tracheostomy care for residents on EBP. This inconsistency in following established infection control protocols led to the deficiency identified during the survey.