Failure to Follow Infection Control Protocols During Tracheostomy Care
Penalty
Summary
A deficiency was identified during tracheostomy care for a resident with a history of acute respiratory failure with hypoxia, anoxic brain damage, and congestive heart failure, who was in a persistent vegetative state and had a tracheostomy. During observation, the Respiratory Therapist (RT) failed to disinfect the table before placing tracheostomy supplies on it and opened a sterile suction tray while wearing gloves that had already been used. The RT then contaminated the sterile gloves by touching them with the dirty gloves and proceeded to suction the resident. After suctioning, the RT did not remove the inner pair of gloves or sanitize hands before donning a new pair of clean gloves, and continued to handle sterile supplies and perform care without proper hand hygiene or glove changes as required by facility policy. Interviews with the RT and the Director of Nursing confirmed that the RT did not follow infection control protocols, including failing to disinfect surfaces, contaminating sterile gloves, and not performing hand hygiene between glove changes. Review of the facility's tracheostomy care policy indicated that gloves should be changed and hands sanitized at specific steps, which was not followed during the observed care. These actions and inactions led to a failure to adhere to infection prevention and control guidelines during tracheostomy care for the resident.