Failure to Maintain Sterile Technique During Tracheostomy Care
Penalty
Summary
A deficiency was identified when a respiratory therapist (RT) failed to maintain proper infection control measures during tracheostomy care for a resident with chronic respiratory failure, cerebral infarction, and a tracheostomy. The resident, who was in a persistent vegetative state and required ongoing tracheostomy care, was observed during a routine procedure where the RT donned a gown, washed hands, and applied gloves before beginning care. During the process, the RT touched the light cord with a sterile gloved hand to improve visibility, then continued the procedure without changing gloves or re-washing hands, thereby contaminating the sterile field. The RT acknowledged the lapse in aseptic technique during an interview, confirming that she continued care after contaminating her gloves. The facility's policy required the use of aseptic technique and sterile gloves during tracheostomy care, with specific instructions to avoid cross-contamination. However, the policy did not explicitly address the need to avoid touching other surfaces, such as a light cord, during the procedure. The Director of Nursing confirmed that maintaining a sterile field is necessary and that touching other items during care constitutes an infection control issue. This incident had the potential to affect other residents with tracheostomies in the facility.