Failure to Use PPE and Perform Hand Hygiene During Tracheostomy and PEG Tube Care
Penalty
Summary
The facility failed to ensure that appropriate personal protective equipment (PPE) was worn and proper hand hygiene was performed during the care of a resident with a tracheostomy and a percutaneous endoscopic gastrostomy (PEG) tube, who was under enhanced barrier precautions (EBP) due to the presence of medically invasive devices. During an observation, two nurses, an LPN and an RN, entered the resident's room, which was clearly marked for EBP and had PPE available outside the door, but neither donned any PPE before providing tracheostomy and PEG tube care. The resident, who had diagnoses including acute and chronic respiratory failure and required regular tracheostomy and PEG tube care, was observed coughing during the procedure, which included suctioning and removal of the inner cannula. After removing the resident's inner cannula, the LPN removed her gloves without performing hand hygiene and searched through supplies in the room with bare hands. The RN, after removing the old split gauze dressing from the PEG tube site, also removed her gloves without performing hand hygiene before leaving the room to retrieve a needed supply. Both nurses only performed hand hygiene upon the RN's return to the room, prior to resuming care. Interviews with both nurses confirmed their awareness of the EBP requirements and the need for PPE and hand hygiene, but acknowledged that these protocols were not followed during the observed care. Review of facility policies confirmed that EBP required gown and gloves for high-contact care and that hand hygiene was mandated after glove removal and before handling invasive devices or environmental surfaces. The failure to adhere to these protocols was observed and confirmed through staff interviews, record review, and policy review, affecting one resident who required enhanced infection prevention measures due to his medical condition.