Failure to Maintain Sterile Technique During Tracheostomy Care
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to provide sterile tracheostomy care to a resident requiring respiratory support. During an observed tracheostomy care procedure, the LVN did not maintain sterile technique, did not perform hand hygiene at appropriate steps, and failed to change gloves between dirty and clean tasks. Specifically, after removing gloves and opening a sterile glove package, the LVN did not sanitize her hands before donning new sterile gloves, handled supplies with sterile gloves, and did not change gloves or perform hand hygiene after removing the old dressing and before applying a clean one. These actions were inconsistent with both professional standards of practice and the facility's own tracheostomy care policy, which requires hand hygiene and the use of clean supplies at each step. The resident involved was a cognitively intact female with acute and chronic respiratory failure, an artificial larynx, and a care plan requiring tracheostomy care and oxygen therapy. The resident's physician orders and care plan specified regular tracheostomy care, including changing and dating trach ties and dressings. The LVN and the Director of Nursing both acknowledged during interviews that the procedure should have been performed using sterile technique to reduce infection risk, and that the correct steps were not followed during the observed care.