Failure to Follow Enhanced Barrier Precautions During Tracheostomy Care
Penalty
Summary
The facility failed to follow its own infection prevention and control protocols during tracheostomy care and suctioning for a resident with multiple complex medical conditions, including metabolic encephalopathy, respiratory failure, spinal cord injury, diabetes, quadriplegia, gastrostomy, and tracheostomy. During an observed care episode, a respiratory therapist did not use enhanced barrier precautions as required, did not change gloves or perform hand hygiene when moving from dirty to clean tasks, and used soiled gloves to initiate a sterile procedure. The therapist also failed to use a gown, did not change the drain gauze after suctioning, and handled suction tubing and supplies in a manner inconsistent with sterile technique, including using a suction tube that had been left open to air and not properly disposing of soiled equipment. Interviews with facility leadership confirmed that the expected practice was to use enhanced barrier precautions, including gown use, glove changes, and hand hygiene, especially when caring for residents with indwelling medical devices such as tracheostomies. Facility policies also required the use of sterile technique for suctioning and proper handling of supplies. The observed actions were inconsistent with these policies, and the staff member involved acknowledged not following the enhanced barrier precautions, citing the procedure as quick and clean. The deficiency was identified through direct observation, staff interviews, and review of facility policies.