Failure to Follow Infection Control Protocols During Tracheostomy Care
Penalty
Summary
Unit Manager #2 failed to adhere to professional standards of practice and infection prevention protocols during tracheostomy care for a resident with quadriplegia and a tracheostomy. During a continuous observation, the Unit Manager removed soiled split gauze and a soiled inner cannula from the resident's tracheostomy site, disposed of them, and then proceeded to handle clean supplies and perform subsequent tasks without changing gloves and performing hand hygiene between the soiled and clean portions of the procedure. The Unit Manager only removed gloves and performed hand hygiene after completing the entire care process, including handling both soiled and clean items. Interviews with the Unit Manager revealed a lack of awareness regarding the need to change gloves and perform hand hygiene between handling soiled and clean materials during tracheostomy care. The Infection Preventionist and Administrator both confirmed that the expected standard of care would require splitting the procedure into soiled and clean parts, with appropriate glove changes and hand hygiene to prevent the spread of disease-causing organisms to the resident's airway. The failure to follow these protocols was directly observed and confirmed through staff interviews.