Failure to Provide Proper Perineal Care
Penalty
Summary
The facility failed to provide necessary services to maintain good grooming and personal hygiene for a resident, identified as Resident 65, who required assistance with activities of daily living (ADLs). The deficiency was observed during an inspection where a Certified Nursing Assistant (CNA) did not follow the proper procedure for perineal care. The CNA did not perform hand hygiene before putting on gloves, used washcloths that were not properly sanitized, and did not follow the facility's policy and procedure for perineal care. Resident 65, who had been admitted to the facility with diagnoses including type 2 diabetes mellitus and generalized muscle weakness, required substantial assistance with ADLs due to moderately impaired cognition. The resident's care plan indicated the need for assistance with personal hygiene and toileting every shift. However, during an observation, the CNA failed to clean the overbed table before placing washcloths, did not use separate basins for soapy and rinse water, and did not ensure the washcloths were at a comfortable temperature for the resident. Interviews with the CNA and the Director of Staff Development confirmed that the CNA did not adhere to the facility's procedures for perineal care, which included washing hands, using clean washcloths for each stroke, and ensuring the resident's comfort. The Director of Nursing also confirmed that the failure to follow these procedures could affect the resident's dignity, quality of life, and increase the risk of infection.
Plan Of Correction
Glove use, sanitizing the overbed table before and after use, and not exiting the resident's room with gloves on 3/20/25. The DSD orients all nursing employees at the time of hire, annually, and as needed regarding the facility's Activities of Daily Living responsibilities, including providing grooming care with hand washing, proper glove use, and removing gloves prior to exiting the residents' rooms. D. How the facility plans to monitor its performance to make sure solutions are sustained: The Director of Staff Development will randomly assess certified nurse aide grooming skills through the day when on shift to ensure grooming assistance is provided in a manner that supports the resident's psychosocial well-being. The Infection Prevention will monitor certified nurse aides' infection control practices, including donning and doffing gloves when required, removing gloves prior to exiting a resident's room following care, and cleaning and sanitizing overbed tables when used. The Director of Activities will ask residents if there are any concerns related to nursing care during the resident council meeting to identify any non-compliance with grooming. The Director of Staff Development/designee will report significant trends identified with resident grooming concerns, hand washing, and cleaning and sanitizing overbed tables during use for cares to the resident altercations to the QAPI/QAA Committee at least quarterly for the purpose of process improvement through root cause analysis and committee-recommended interventions to ensure continued compliance with this plan of correction. Allegation of Compliance Date: 3/25/2025 F684 A. How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: Resident 197 discharged on 3/4/25. Resident's MD declined to have thyroid hormone level checked after the discovery of missed doses. MD was notified about the missed doses on 2/28/25 with no new orders. B. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action was taken: The Director of Nursing audited residents who receive Levothyroxine on 3/21/2025 to identify residents who did not receive the medication.