Inadequate Incontinent and Perineal Care Provided to Two Residents
Penalty
Summary
Two residents were found to have received inadequate incontinent care, as observed and documented by surveyors. One resident, who was cognitively intact and fully dependent on staff for toileting, was left without incontinent care from the morning until the afternoon. When care was provided, the certified nurse aide (CNA) used improper technique, including using a single wet washcloth without soap for multiple wipes, not cleaning the perineal area in the correct direction, failing to dry the area, and not changing gloves between tasks. The CNA also touched various surfaces and equipment in the room and hallway while wearing soiled gloves, increasing the risk of cross-contamination. The resident was experiencing a bowel movement during care, and the CNA did not follow proper infection control or perineal care procedures as outlined in the facility's protocols. Another resident, who was always incontinent of bowel and bladder and required substantial assistance, did not receive complete perineal care during toileting. The CNA failed to retract and clean under the foreskin while performing peri care, a step acknowledged as necessary by the staff involved. Both incidents were confirmed through interviews with the CNAs and the Clinical Care Coordinator, who stated that staff are expected to follow the facility's established procedures for perineal care and infection control.