Failure to Change Gloves During Incontinence Care for Resident on Enhanced Barrier Precautions
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to change gloves during incontinence care for a resident with a history of ESBL (Extended-spectrum beta-lactamase) in the urine, despite physician orders and care plan instructions for Enhanced Barrier Precautions. During observed care, a CNA removed a soiled incontinence brief, cleansed the resident's perineal area, applied a clean brief, assisted with clean clothing, handled a mechanical lift remote, and combed the resident's hair without changing gloves between tasks. The CNA admitted to not changing gloves as required and was unaware of the specific reason for the resident's precautions. The Director of Nursing confirmed that gloves should be changed when moving from dirty to clean tasks, especially for residents with a history of ESBL, to prevent the spread of infection.