Failure to Provide Proper Perineal Care for Incontinent Resident
Penalty
Summary
A certified nursing assistant (CNA) failed to provide appropriate perineal care to a female resident who was incontinent of bowel and bladder. During an observed episode of incontinence care, the CNA did not separate the resident's labia or clean the base of the labia, as required by facility policy and standard perineal care procedures. The CNA acknowledged during an interview that she forgot to perform this step due to nervousness. The Director of Nursing (DON) confirmed that the CNA had previously demonstrated correct perineal care skills during a competency check-off, but did not follow the correct procedure during the observed care. The resident involved had severe cognitive impairment, was dependent on staff for all activities of daily living, and had a history of frequent urinary and constant bowel incontinence. The resident's care plan included monitoring for signs and symptoms of urinary tract infection. Facility policy specifically required separating the labia and cleaning from front to back during female perineal care, which was not followed in this instance.