Failure to Change Gloves During Incontinence Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to change gloves during the process of providing incontinence care to a resident. Video evidence showed the CNA performing multiple tasks, including adjusting bedding, handling clean and soiled items, and cleaning the resident's perineal and buttocks areas, all without changing gloves between tasks. The CNA touched various surfaces and moved between soiled and clean body sites without removing or replacing gloves, contrary to standard infection control practices. The incident involved a resident receiving incontinence care with the assistance of another CNA. The CNA in question handled both soiled and clean items, as well as the resident's body, without changing gloves at any point during the care process. The Director of Nursing was unable to confirm that glove changes were required between soiled and clean body sites, instead referencing hand hygiene expectations. However, CDC guidelines specify that gloves should be changed when moving from a soiled to a clean body site on the same patient.