Failure to Follow Infection Control Practices for Tracheostomy Care and Glucometer Cleaning
Penalty
Summary
Surveyors identified a failure to follow infection prevention and control practices related to glucometer cleaning and use of personal protective equipment (PPE) and hand hygiene. During a random observation of the insulin cart, a glucometer was found with two visible spots of blood on the machine, despite facility policy stating that glucometers must be cleaned and disinfected after each use on each patient. In an interview, a registered nurse confirmed there should be no blood on glucometers and that they are to be cleaned between each use. In a separate observation of tracheal suctioning for a resident on Enhanced Barrier Protocol (EBP) due to a tracheostomy, multiple infection control breaches were observed. The RN performing the procedure did not wash hands before donning gloves and did not wear a gown, and two CNAs who entered the room to assist with repositioning the resident also did not don gowns, although they wore gloves. The RN used the same gloves to open the tracheostomy care kit and sterile water, then removed gloves and washed hands before donning a single sterile glove on the right hand. The RN then touched the trach collar with the sterile gloved hand, did not remove the glove or perform hand hygiene, and subsequently touched the suction catheter with a now-contaminated glove without changing to a new sterile glove or washing hands. The RN proceeded to perform multiple suction passes, cleared the catheter with sterile water, placed the catheter into a container uncurled, reattached the trach collar, and then removed gloves and discarded the suction catheter. In interviews, the RN, CNAs, and Infection Preventionist acknowledged that gowns should have been worn for EBP and that gloves should be changed when moving from dirty to clean tasks, and that glucometers should be cleaned after each use. Facility policies on hand hygiene, PPE, and glucometer cleaning supported these requirements.
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