Failure to Change Gown Between Residents During Care Activities
Penalty
Summary
Certified Nursing Assistant (CNA) 1 failed to follow infection control policies and procedures when providing care to two residents. After repositioning one resident who was severely cognitively impaired and dependent on staff for activities of daily living, CNA 1 washed her hands and changed gloves but did not change her gown before proceeding to drain the urinary catheter of another resident in the same room. The second resident had a diagnosis of osteomyelitis and acute kidney failure, required substantial assistance, and had physician orders for enhanced barrier precautions and continuous Foley catheter drainage. CNA 1 acknowledged during the observation that she did not change her gown as required to prevent contamination between residents. The Director of Nursing confirmed that CNA 1 did not follow the facility's infection control protocols, which require staff to change gowns between care activities for residents under isolation precautions. The facility's infection prevention and control policy, last reviewed in June 2025, mandates measures to prevent the development and transmission of infection in accordance with federal and state requirements. The failure to change gowns between residents had the potential to cause cross-contamination.