Improper Tracheostomy Care and Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to provide tracheostomy care consistent with professional standards for one resident who required ongoing respiratory services. The resident was admitted with metabolic encephalopathy and respiratory failure and was documented on the quarterly MDS as severely cognitively impaired and receiving oxygen therapy, suctioning, respiratory services, and tracheostomy care. The resident’s care plan included a goal of having no abnormal drainage around the tracheostomy site and interventions such as instructing the resident or caregiver in tracheostomy care and suctioning. During an observed tracheostomy care procedure, the respiratory therapist (RT) performed hand hygiene and applied two pairs of clean disposable gloves, then opened a tracheostomy care tray on the resident’s overbed table without cleaning the work surface. The RT poured normal saline into the tray and used gauze saturated with saline to clean around the tracheostomy site, then placed the dirty gauze on a dressing package on the overbed table. The RT subsequently placed additional soiled gauze back into the tracheostomy care tray on top of remaining clean gauze and removed clean gauze from under used gauze to continue cleaning the site, thereby mixing clean and dirty supplies. The RT also used cotton-tipped applicators saturated with saline to clean around the site and continued to place used items in the same tray containing clean supplies. The RT removed the top pair of gloves before opening and applying a clean dressing but did not perform hand hygiene before applying the dressing. In interviews, the RT stated she had been trained to work from the tracheostomy care tray, was unaware she needed to clean the work surface before setup, and believed she had been instructed to double glove, although the third shift supervisor denied giving such a directive. The Director of Respiratory Therapy reported that the department followed Lippincott’s guidance for hand hygiene, had no written tracheostomy care policy, and that tracheostomy care was taught at the bedside. The Infection Preventionist and DON both stated expectations that staff should not contaminate clean areas, should perform hand hygiene, and should not go from dirty to clean during care. The physician interviewed stated he would expect clean gloves between dirty and clean tasks, that double gloving was not appropriate PPE, and that staff should not take shortcuts with hand hygiene.
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