Failure to Maintain Sterile Technique During Tracheostomy Care
Penalty
Summary
Nurse #4 failed to maintain sterile technique during tracheostomy care for a resident in a persistive vegetative state with a tracheostomy. During the procedure, Nurse #4 performed hand hygiene and donned clean gloves, then removed the trach cap, soiled gauze, and inner cannula. Without performing hand hygiene or donning sterile gloves, she handled and inserted a new sterile inner cannula and placed clean split gauze. Additionally, when preparing to suction the resident, Nurse #4 donned sterile gloves over soiled gloves rather than removing the soiled gloves and performing hand hygiene first. Interviews with facility leadership, including the DON, Administrator, and Infection Preventionist, confirmed that Nurse #4 did not follow proper infection control protocols, specifically failing to perform hand hygiene and don sterile gloves before handling sterile items. The improper technique was observed during direct care and acknowledged by the nurse involved, as well as by facility leadership, who stated that these actions did not meet professional standards of practice for infection prevention.