Failure to Change Gloves Between Soiled and Clean Incontinence Care
Penalty
Summary
Staff failed to change gloves between providing soiled incontinence/perineal care and applying clean incontinence briefs for multiple residents. During an early morning observation, two CNAs assisted a resident with dementia and altered mental status who was incontinent of urine in bed. After removing the soiled brief and performing peri care with disposable wipes, one CNA did not change gloves before helping apply a clean brief. This resident’s admission MDS was still in progress and there was no care plan addressing incontinence care at the time of review. In separate observations, another resident with Alzheimer’s disease, dementia, overactive bladder, severe cognitive impairment, and a care plan for intermittent bowel and bladder incontinence received peri care while sitting on the edge of the bed; the assisting CNA did not change gloves before placing a clean brief. A third resident with spastic hemiplegia, cerebral infarction, overactive bladder, severe cognitive impairment, and total incontinence of bowel and bladder was provided incontinent peri care by a CNA who then neither washed hands nor changed gloves before applying a clean brief. The CNA later stated that gloves should have been changed after providing incontinence care and before placing clean briefs. The facility’s incontinence policy stated that incontinent residents would receive appropriate treatment and services, including treatment to prevent infections.
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