Failure to Change Gloves Between Dirty and Clean Tasks During Personal Care
Penalty
Summary
Certified Nursing Assistant (CNA) 26 failed to change gloves between dirty and clean tasks while providing personal care to a resident who was dependent on staff for all activities of daily living due to severe cognitive impairment, limited mobility, and multiple medical conditions including heart failure, diabetes, and dementia. During the observed care, CNA 26 removed the resident's soiled brief and cleaned the resident's private area with gloved hands, then, without changing gloves, handled a clean brief and repositioned the resident, completing the care with the same pair of gloves. When questioned, CNA 26 acknowledged using only one pair of gloves throughout the procedure and admitted that the gloves were likely contaminated when touching the clean brief. The facility's policy, as well as statements from the Interim Assistant Director of Nursing and the Director of Nursing, confirmed that staff are expected to change gloves and perform hand hygiene when moving from a soiled to a clean task. The failure to follow this protocol was directly observed and confirmed through staff interviews and record review.