Failure to Provide Timely and Proper Incontinent Care with Infection Control Lapses
Penalty
Summary
Facility staff failed to provide timely and appropriate incontinent care to a resident who was dependent on staff for all toileting hygiene and had a history of bowel and bladder incontinence, as well as a pre-admission stage 2 pressure injury at the sacrum. The resident, who was cognitively intact and able to communicate, reported requesting incontinent care from two staff members over a period of more than two hours, during which no staff entered the room to provide assistance. The room developed a foul odor during this time, and the resident confirmed that care had not been provided. When two CNAs eventually entered the room to provide care, multiple deficiencies in infection control and care technique were observed. Both CNAs failed to use hand sanitizer or perform hand hygiene at any point during the care, changed gloves without sanitizing hands, and reused cleaning wipes multiple times, tucking used wipes into the soiled brief. The CNAs also failed to thoroughly clean the resident, as evidenced by a large amount of fecal material remaining after they stated care was complete. Only after intervention by a restorative CNA, who followed proper infection control procedures, was the resident fully cleaned. Interviews with the CNAs and the DON confirmed that proper procedures for hand hygiene and thorough cleaning were not followed during the provision of incontinent care. The DON acknowledged that the care provided did not meet expectations. Additionally, the facility was unable to provide a policy for incontinent care or hand washing when requested by the surveyor.