Failure to Follow Infection Control During Tracheostomy Care
Penalty
Summary
The facility failed to adhere to infection control standards during tracheostomy care for two residents with respiratory failure and tracheostomy status. In both cases, nursing staff did not sanitize their hands or change gloves at critical points during the procedure, despite handling visibly soiled materials and moving between different steps of care. Specifically, one nurse removed soiled tracheostomy ties and neck collar, handled the inner cannula, and inserted a new cannula without changing gloves or sanitizing hands. The same gloves were used to handle clean supplies after touching contaminated items, and the nurse only sanitized hands after completing the entire procedure and doffing gloves and gown. A second nurse also failed to change gloves or sanitize hands after inserting a new inner cannula and before cleaning around the stoma, removing soiled dressings, and replacing the neck strap and ties. This nurse continued to perform multiple steps of tracheostomy care, including handling soiled and clean items, without changing gloves or sanitizing hands. In both cases, the Infection Preventionist assisted but did not intervene to correct the infection control breaches during the procedures. Both residents involved were severely cognitively impaired and required ongoing tracheostomy care as part of their care plans. The observations were corroborated by staff interviews, where the nurses acknowledged the lapses in infection control and the Infection Preventionist confirmed awareness of the required procedures. The Director of Nursing stated an expectation that all infection control procedures be followed during tracheostomy care.