Failure to Follow Infection Control Protocols During Perineal Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during the provision of incontinent care for three staff members observed. Specifically, staff did not follow proper perineal care procedures for two male residents who were always incontinent. During observations, one CNA reused wipes by folding them instead of using a new wipe for each stroke, and did not retract and clean the foreskin of an uncircumcised resident. Another instance involved staff cleaning from back to front rather than the required front to back method. These actions were contrary to the facility's perineal care policy, which specifies the use of the one wipe, one swipe technique and proper cleaning of the foreskin for uncircumcised males. The residents involved had significant medical histories, including severe cognitive impairment, hypertension, lack of coordination, diabetes mellitus, generalized edema, and peripheral vascular disease. Despite recent in-service training and documented competencies indicating that staff had met pericare skills, the observed failures in technique placed residents at risk for infection. Interviews with the DON confirmed that the observed practices did not align with facility policy and could have led to infection, particularly due to improper cleaning of the foreskin and incorrect wiping technique.