Failure to Maintain Sterile Technique and Hand Hygiene During Tracheostomy Care
Penalty
Summary
A deficiency occurred when a resident with a tracheostomy did not receive respiratory care consistent with professional standards of practice. The facility's policy required aseptic technique and sterile gloves during tracheostomy care, as well as adherence to hand hygiene protocols. During an observed tracheostomy care procedure, an LPN failed to maintain sterile technique and did not follow proper hand hygiene practices at multiple points throughout the procedure. The LPN placed tracheostomy care supplies on an unclean bedside table that contained used cups, dried sticky material, and an empty urinal, without cleaning the surface beforehand. The LPN handled sterile items with non-sterile gloves, contaminating the sterile kit, and placed sterile gloves and other items on the unclean table. The LPN also used a bottle of normal saline that was not sterile and failed to establish a sterile field for the procedure. Throughout the process, the LPN repeatedly failed to perform hand hygiene after removing gloves, as required by facility policy and CDC guidelines. Additionally, the LPN did not check the resident's neck for skin breakdown from the tracheostomy necktie during the procedure, despite indicating that this should be part of the care. The Director of Nursing confirmed that the expected standard of practice was not followed, including cleaning the work area, maintaining sterility, and performing hand hygiene at appropriate times.