GRAND FORKS, ND - Federal inspectors documented multiple infection control violations at Woodside Village nursing home during a January 8, 2025 inspection, finding staff failed to follow proper hygiene protocols during critical medical procedures including tracheostomy care and insulin administration.
Contaminated Glove Use During Tracheostomy Care
The most significant violation involved improper infection control practices during tracheostomy care for a resident with enhanced barrier precautions who had recently experienced an Influenza A infection. On January 9, inspectors observed a nurse performing complex respiratory care while failing to follow basic contamination prevention protocols.
During the observed procedure, the nurse initially followed proper protocol by applying protective gear and completing the sterile portion of tracheostomy care correctly. However, after removing sterile gloves and applying clean gloves for non-sterile care, the nurse's actions created multiple contamination risks.
The nurse removed a used paper napkin that the resident had coughed into, cleaned the tracheostomy site with cotton swabs and cleaning solution, then handed the same contaminated napkin back to the resident. Using the same gloves that had contacted respiratory secretions, the nurse then touched numerous items throughout the resident's room before finally removing protective equipment and leaving.
This sequence violated fundamental infection control principles by failing to change gloves after handling contaminated materials. The facility's own policy clearly states that hand hygiene is required "after contact with blood, body fluids or contaminated surfaces" and emphasizes that "the use of gloves does not replace hand washing/hygiene."
Medical Significance of Tracheostomy Infection Control
Tracheostomy patients face elevated infection risks due to their compromised respiratory systems and direct airway access. The tracheal opening bypasses natural defense mechanisms, making these residents particularly vulnerable to respiratory tract infections and pneumonia. When a patient already has influenza, as in this case, strict infection control becomes even more critical.
Proper tracheostomy care protocols require healthcare workers to treat respiratory secretions as highly infectious material. After any contact with secretions or contaminated surfaces, gloves must be changed and hand hygiene performed before touching other surfaces or continuing care. This prevents cross-contamination that could spread respiratory infections to other vulnerable residents.
The observed violation created multiple infection transmission pathways - from the contaminated napkin back to the resident's hands, from the same gloves to various room surfaces, and potentially to other residents through environmental contamination.
Insulin Administration Without Protective Equipment
A second infection control violation occurred during insulin administration, where inspectors observed a nurse performing injections without wearing gloves. On January 8, a nurse was seen administering both Insulin Glargine and Novolog injections to a diabetic resident after performing hand hygiene but without applying gloves for the procedure.
This practice violates both facility policy and standard medical protocols for injection administration. The facility's insulin injection policy explicitly requires healthcare workers to "apply clean gloves" before administering injections, following proper hand hygiene and equipment preparation.
Injection Safety and Bloodborne Pathogen Risks
Insulin injections require glove use due to potential exposure to blood and body fluids. Even when using safety-engineered injection devices, healthcare workers face risks from needle stick injuries and blood contact. Gloves provide essential protection against bloodborne pathogens including hepatitis B, hepatitis C, and HIV.
Standard precautions established by the Centers for Disease Control and Prevention require gloves during any procedure involving potential blood exposure. This includes all injections, regardless of the injection site or patient population. The protocol protects both healthcare workers and prevents cross-contamination between patients.
Additionally, diabetic patients often have compromised immune systems and slower wound healing, making them more susceptible to injection site infections. Proper glove use during insulin administration helps prevent introducing bacteria from healthcare workers' hands into injection sites.
Facility Policy Standards and Staff Understanding
Administrative staff at Woodside Village confirmed they maintained appropriate expectations for infection control practices. During interviews, two administrative nurses stated they expected staff to remove contaminated gloves and perform hand hygiene before moving to other tasks. An administrative staff member confirmed that nurses should wear gloves while administering injections.
The disconnect between established policies and observed practices suggests implementation gaps rather than inadequate standards. The facility had comprehensive written policies covering both hand hygiene requirements and injection procedures, but staff were not consistently following these protocols during patient care.
Industry Standards and Best Practices
Healthcare facilities must maintain infection prevention and control programs that comply with federal standards and evidence-based practices. These requirements exist because healthcare-associated infections affect millions of patients annually and can lead to serious complications, extended hospitalizations, and increased mortality rates.
Proper glove use and hand hygiene represent fundamental infection control measures that prevent transmission of infectious agents between patients, healthcare workers, and the environment. These practices are particularly crucial in nursing homes, where residents often have multiple chronic conditions and compromised immune systems that increase infection susceptibility.
The violations at Woodside Village represent failures in basic infection control practices that could have serious consequences. Respiratory infections can spread rapidly through nursing home populations, while bloodborne pathogen exposures create both immediate and long-term health risks.
Additional Issues Identified
The inspection also referenced a previous wheelchair safety violation involving a certified nursing assistant who transported a resident without properly positioning foot pedals, resulting in a fall incident. The facility had implemented corrective actions including staff education, administrative leave for the involved employee, and ongoing quality assurance audits for wheelchair transport procedures.
The combination of infection control violations and previous safety issues suggests systemic challenges in ensuring consistent adherence to established care protocols throughout the facility. While individual violations may seem minor, they represent broader patterns that could compromise resident safety and quality of care.
Federal inspectors classified the infection control violations as having "minimal harm or potential for actual harm" affecting "few" residents. However, infection control breaches have the potential to impact far more residents than those directly involved in the observed incidents, as infectious agents can spread throughout healthcare facilities when proper precautions are not maintained.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Woodside Village from 2025-01-08 including all violations, facility responses, and corrective action plans.
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