The nurse failed to wear a gown required for Enhanced Barrier Protocol patients and contaminated sterile supplies during the January 23 procedure. Two nursing assistants who helped move the patient also entered the room without gowns, though both wore gloves.
Inspectors observed the registered nurse open a sterile tracheostomy care kit with contaminated gloves, then touch the patient's trach collar with a sterile-gloved hand before handling a suction catheter with the same dirty glove. The nurse never changed gloves between dirty and clean tasks during the procedure.
The nurse removed gloves, washed hands for 60 seconds, then put on a sterile glove on the right hand only. She touched the trach collar with the sterile glove, then grabbed the suction catheter with a dirty-gloved hand without changing gloves or washing hands.
She passed the suction catheter into the tracheostomy with suction on, cleared it with sterile water, and performed two more passes. The catheter went into a container uncurled before she reattached the trach collar and removed gloves.
The patient was on Enhanced Barrier Protocol specifically because of the tracheostomy, which requires staff to wear gowns when entering the room.
When questioned, the registered nurse admitted she should have worn a gown. Both nursing assistants also acknowledged they should have worn gowns during the procedure.
A day earlier, inspectors found a glucose meter on the facility's insulin cart with two visible blood spots. The meter had not been cleaned between patient uses, despite facility policy requiring cleaning and disinfection after each patient.
A registered nurse interviewed about the glucose meter said there should be no blood on the machines and confirmed they are supposed to be cleaned between each use.
The facility's infection preventionist explained that patients in high-contact circumstances like tracheostomies should have Enhanced Barrier Protocol signs on their doors, requiring proper personal protective equipment. She said gloves should be changed when going from dirty to clean tasks, and glucose meters must be cleaned after each use.
River Bend's own policies supported the inspectors' findings. The facility's hand hygiene policy from October 2023 states hand hygiene is required when performing aseptic tasks and immediately after glove removal. It specifies that staff must perform hand hygiene before applying non-sterile gloves.
The personal protective equipment policy from October 2018 indicates the type of PPE required depends on transmission-based precautions and lists gowns among required equipment.
The facility's glucose meter policy specifically states: "The meter should be cleaned and disinfected after use on each patient."
The violations occurred during a complaint investigation completed January 30. Inspectors classified the infection control failures as having minimal harm or potential for actual harm, affecting few residents.
The registered nurse's contamination of sterile equipment during tracheostomy care created multiple opportunities for infection. Touching the trach collar with a sterile glove, then handling a suction catheter with dirty gloves before inserting it into the patient's airway, violated basic sterile technique.
The glucose meter violations meant multiple patients potentially had blood exposure through contaminated equipment. Blood-borne pathogens can survive on surfaces and medical devices, creating transmission risks between patients when equipment isn't properly cleaned.
Federal regulations require nursing homes to maintain infection prevention and control programs to protect residents from healthcare-associated infections. The failures at River Bend demonstrated systemic breakdowns in both policy implementation and staff training on basic infection control procedures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for River Bend Nursing and Rehabilitation from 2026-01-30 including all violations, facility responses, and corrective action plans.