Failure to Follow Hand Hygiene and PPE Protocols During Tracheostomy Care
Penalty
Summary
The deficiency involves a failure to follow infection prevention and control protocols during tracheostomy care for one resident who had a physician order for enhanced barrier precautions related to tracheostomy care. During an observation of tracheostomy care, an LPN began the procedure and then discovered that needed supplies were not available in the resident’s room. The LPN removed their gloves and gown and left the room to obtain supplies. When the LPN returned with the supplies, they donned a gown and gloves in the room but were not observed to perform hand hygiene before putting on the new PPE. During the continuation of the tracheostomy care, the LPN opened a pair of sterile gloves, removed the existing gloves, and donned the sterile gloves without performing hand hygiene between glove changes. The LPN then opened supplies, used an alcohol wipe to clean the inner cannula, cleaned the area around the tracheostomy site, and placed the inner cannula without changing gloves between cleaning the site and inserting the cannula. While still wearing the same gloves, the LPN removed the old collar, cleaned the area around the site, opened a new collar, took a pen from a uniform pocket to label the collar, placed the new collar, gathered trash, and left the room. The facility’s hand hygiene policy required hand sanitizing before applying and after removing PPE, before and after handling clean or soiled dressings, and after handling items potentially contaminated with blood or bodily fluids. The DON stated that hand washing or sanitizing should occur before starting a procedure, between glove changes, and when the procedure was over.
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