Failure to Maintain Infection Control During Tracheostomy Care
Penalty
Summary
A deficiency was identified when a registered nurse (RN) failed to adhere to infection prevention and control protocols during tracheostomy care for a resident with significant medical needs, including anoxic brain damage, acute respiratory failure, dysphagia, and a tracheostomy. The RN did not perform hand hygiene before donning gloves or between glove changes, and handled various items in the environment, such as the medication cart and light switch, with contaminated gloves before providing direct care. The RN also failed to sanitize the bedside table before placing sterile supplies and placed sterile items on a surface that was not properly prepared, with other non-sterile items present. During the tracheostomy care procedure, the RN used a yankauer suction device that was tested in an open, unlabeled, and undated container of clear fluid at the resident's bedside, rather than using sterile water or saline as required. The yankauer was then used to attempt suctioning and subsequently returned to its packaging without proper disinfection. The RN also donned sterile gloves without performing hand hygiene, allowed the gown to touch the outside of the gloves, and turned away from the sterile field, all of which compromised the sterility of the procedure. Additionally, the RN did not monitor the resident's oxygen saturation during care, as ordered, and adjusted the oxygen flow without following established protocols. Interviews with other staff members, including licensed vocational nurses, certified nursing assistants, the assistant director of nursing, and the director of nursing, confirmed that the observed practices did not align with facility policy or accepted standards for infection control. Staff acknowledged that hand hygiene should be performed before and after care, between glove changes, and before handling sterile supplies. The facility's in-service records showed no recent training on tracheostomy care, and the policies reviewed emphasized the importance of hand hygiene and proper handling of sterile supplies, which were not followed in this instance.