Failure to Use Sterile Technique and Perform Hand Hygiene During Tracheostomy Care
Penalty
Summary
Nurse #1 failed to use sterile gloves and did not perform hand hygiene while providing tracheostomy care to a resident with a history of acute respiratory failure and a tracheostomy. During the observed care, Nurse #1 set up supplies without a tracheostomy kit, donned non-sterile gloves, and removed the resident's dirty dressing. After doffing gloves, Nurse #1 did not sanitize her hands before donning new gloves and continued care, including removing and replacing the inner cannula, all without using sterile technique or performing hand hygiene between glove changes. Handwashing was only performed at the end of the procedure. The resident's care plan and physician orders required tracheostomy care with attention to infection prevention. Interviews with Nurse #1 revealed she was aware of the missed hand hygiene but was not aware that sterile gloves were required for tracheostomy care. The Infection Preventionist/ADON and DON both stated their expectations for proper infection control practices, including hand hygiene and sterile technique, but were not aware of the specific deficiencies observed during this incident.