Failure to Provide Proper Incontinence Care and Prevent UTI
Penalty
Summary
A deficiency occurred when a resident who was always incontinent of bowel and bladder did not receive appropriate incontinence care to prevent urinary tract infections. The resident, a female with diagnoses including heart failure, kidney failure, diabetes, stroke, and Alzheimer's disease, was found to be wearing two soaked disposable briefs, a practice known as double-briefing, which is not permitted by facility policy. Certified Nursing Assistant (CNA) N admitted to double-briefing the resident due to being in a hurry and also reported not changing the resident as frequently as required, only twice during her shift instead of every two hours. Both CNAs involved were unsure when the resident was last changed, and the resident was observed to be soaked with urine that had penetrated her clothing and wheelchair towel. Additionally, CNA O, who was responsible for cleaning the resident, did not thoroughly cleanse the vaginal area, failing to open the labia major and minor as required for proper perineal care. CNA O acknowledged this lapse, attributing it to nervousness, and recognized that inadequate cleansing could lead to infection. The facility's policy requires thorough cleaning from front to back and checking for incontinence at least every two hours, but these procedures were not followed. The Director of Nursing confirmed that CNAs are trained and checked for competency in incontinence care and that double-briefing and untimely care are not acceptable practices.