Failure to Maintain Infection Control During Tracheostomy Care
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) failed to maintain infection control principles during tracheostomy care for a resident with a tracheostomy and Enhanced Barrier Precautions (EBP) in place. The LPN did not perform hand hygiene with alcohol-based hand sanitizer or soap and water prior to entering the resident's room and before donning personal protective equipment (PPE), which included a gown, mask, and gloves. During the care process, the LPN used her gloved hand to push down overflowing trash in the trash can and then, without changing gloves or performing hand hygiene, used the same gloved hand to handle items that would come into direct contact with the resident's tracheostomy, such as a cup for saline solution, the tracheostomy care kit, and the inner-cannula cleaning brush. The process was stopped due to infection control concerns, and the incident was reported to the Director of Nursing (DON). The resident involved had a medical history including tracheostomy, laryngeal stenosis, post-procedural subglottic stenosis, paranoid schizophrenia, drug-induced dyskinesia, and morbid obesity. Physician orders required daily and as-needed tracheostomy care, with specific instructions for cleansing and maintaining aseptic technique. Facility policies on Enhanced Barrier Precautions, Standard Precautions, and Tracheostomy Care all emphasized the importance of hand hygiene and aseptic technique, which were not followed during this observed incident.