Failure to Enforce Infection Control Policy During Tracheostomy Care
Penalty
Summary
Staff failed to adhere to infection prevention and control protocols during tracheostomy care for a resident who was ventilator-dependent and had multiple complex medical conditions, including acute respiratory failure and dependence on renal dialysis. The resident was fully dependent on staff for personal hygiene, including oral care and bathing. During an observation, a respiratory therapist was seen performing tracheostomy care and suctioning while wearing artificial (acrylic) nails, which is against facility policy for staff providing direct care, especially to severely ill or immunocompromised residents. Interviews with facility leadership, including the DON and Infection Preventionist, confirmed that artificial nails are prohibited for staff providing direct care due to the risk of harboring bacteria and increasing the potential for cross-contamination and infection. The respiratory therapist acknowledged wearing artificial nails during care and recognized this as a violation of facility policy. The Infection Preventionist further stated that there was no current system in place to ensure staff compliance with the artificial nail policy, and that artificial nails pose a significant infection control risk, particularly for residents with open wounds, tracheostomies, or ventilators. A review of the facility's hand hygiene policy indicated that artificial fingernails are strongly discouraged for all direct care staff and explicitly prohibited for those caring for severely ill or immunocompromised residents. The policy also grants the infection preventionist the authority to request removal of artificial nails if they are deemed an infection control risk. Despite these policies, the lack of enforcement and monitoring led to a breach in infection control practices during the provision of tracheostomy care.