Failure to Change Gloves and Maintain Infection Control During Resident Care
Penalty
Summary
A Certified Nurse Assistant (CNA) failed to follow proper infection prevention and control procedures while providing care to a resident on enhanced barrier precautions due to a history of extended-spectrum beta-lactamase (ESBL) in the urine and the presence of a suprapubic catheter. The CNA donned personal protective equipment (PPE) before entering the resident's room and assisted the resident with toileting. During the process, the CNA emptied the resident's catheter into a graduate, disposed of a used brief on the bathroom floor instead of in the garbage, and placed the graduate on the floor. The CNA then continued to provide care, including cleansing the resident, pulling up the resident's pants, opening the bathroom door, assisting the resident to a wheelchair and bed, removing the resident's shoes, rearranging the bedside table, and placing the call light within reach—all while wearing the same contaminated gloves used during the initial catheter care. The CNA only removed the contaminated gloves and performed hand hygiene after completing all these tasks and before exiting the room. Upon interview, the CNA acknowledged not changing gloves after emptying the urine, contrary to facility policy and expected infection control practices. The Director of Nursing confirmed that the expectation is for staff to change gloves after such tasks and perform hand hygiene before continuing with other resident care activities.