Failure to Follow Infection Control Protocols During Tracheostomy Care
Penalty
Summary
A deficiency was identified when a nurse failed to adhere to infection prevention and control protocols during tracheostomy care and suctioning for a resident with significant medical needs. The nurse did not perform hand hygiene before and after glove changes, and did not follow sterile technique while suctioning. Specifically, the nurse donned gloves without hand hygiene, used soiled gloves to access personal items, and repeatedly failed to sanitize hands between glove changes. The nurse also used non-sterile equipment and did not properly clean or change necessary items during the procedure. The resident involved was a male with a history of tracheostomy, acute and chronic respiratory failure with hypoxia, gastrostomy, congestive heart failure, cerebral infarction, and dysphagia. He required ongoing oxygen therapy, suctioning, and tracheostomy care, and was assessed as having severe cognitive impairment. Physician orders and care plans specified the need for regular trach care, suctioning, and monitoring for signs of infection, with clear instructions for maintaining sterility and hand hygiene. Facility policies reviewed by surveyors outlined the requirement for hand hygiene before and after resident contact, between glove changes, and after removing gloves, as well as the use of sterile technique for invasive procedures. During interviews, the nurse acknowledged awareness of hand hygiene protocols but cited lack of sanitizer in the room as a reason for non-compliance. The Director of Nursing confirmed expectations for staff to follow infection control policies, including proper hand hygiene and sterile technique during trach care.