Failure to Follow Infection Control Protocols During Tracheostomy Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper infection prevention and control protocols while providing tracheostomy care to a resident with chronic respiratory failure, hypoxia, and a tracheostomy. The LPN did not wear a personal protective gown as required for Enhanced Barrier Precautions, did not consistently perform hand hygiene when changing gloves, and failed to provide a sterile field for supplies. During the care, the LPN touched her hair with gloved hands, reused gloves without hand hygiene, and did not encourage or assist the resident with hand hygiene before, during, or after the procedure. Additionally, the LPN did not clean multi-use equipment, such as a pulse oximeter, after use on the resident. The resident, who was colonized for wounds, had visible drainage on the tracheostomy collar and neck. The LPN and the resident both handled supplies and performed parts of the care without appropriate infection control measures, including the reuse of gauze pads and lack of hand hygiene. Facility policies required the use of gowns and gloves for high-contact care, hand hygiene before and after resident contact, and cleaning of equipment between residents, but these protocols were not followed during the observed care.