Failure to Maintain Infection Control During Tracheostomy Care
Penalty
Summary
During an observation of tracheostomy care for Resident R54, Employee E8 prepared the necessary materials by placing a paper towel on the bed and arranging both clean gauze and other supplies on top of it. While performing suctioning and cleaning the stoma, Employee E8 used gauze from the paper towel, then placed the used, dirty gauze back onto the same paper towel alongside the remaining clean items. The employee continued to pick up additional gauze from the paper towel, resulting in dirty gauze being placed on top of clean gauze and supplies. An interview with Employee E8 at the time of the observation confirmed that dirty gauze was placed on top of clean treatment items during the respiratory care procedure. This practice was found to be inconsistent with the facility's infection prevention and control program, as it failed to prevent the potential development and transmission of communicable diseases during tracheostomy care.