Infection Control Deficiencies in Linen Handling and Tracheostomy Care
Penalty
Summary
Surveyors identified deficiencies in infection prevention and control practices for one of eight sampled residents. During an observation of wound care for a resident with a tracheostomy and a neck wound, a clean isolation gown was found to contain soiled gloves inside the sleeve. This was verified by the LVN present. Interviews with the infection prevention (IP) nurse and Maintenance Director revealed that gowns should be checked for foreign objects before being placed in clean linen storage, but gloves sometimes remained inside gowns after laundering, with the Maintenance Director acknowledging that gloves could melt during washing if not removed. Additionally, the same resident had a physician's order for daily tracheostomy care and wound management. During wound care, the LVN was observed moving a visibly soiled trach tie to access the wound, but did not change the tie after completing the wound care. The soiled trach tie, which had visible discoloration and debris, was only changed after the surveyor's observation and verification by staff. Interviews with the respiratory therapist, IP nurse, and DON confirmed that trach ties should be changed if soiled, regardless of the regular schedule. The facility's policies required staff to minimize the spread of infection, handle linens properly, and change trach ties as needed if soiled. The observed failures to ensure clean linens and to change a soiled trach tie after wound care did not align with these policies, resulting in a deficiency related to infection control practices.