Failure to Provide Proper Incontinence and Hygiene Care
Penalty
Summary
A deficiency was identified when a CNA assisted a resident, who was frequently incontinent of bowel and bladder and had moderate cognitive impairment, with toileting and incontinence care. The CNA did not clean the resident's entire perineal area, buttocks, or thighs after an episode of incontinence, and applied a new brief without ensuring proper hygiene. Additionally, the resident's pants and wheelchair were visibly wet, but the wheelchair was not cleaned before the resident was placed back into it. These actions were observed directly by the surveyor. The resident's care plan required cleaning the perineal area with each incontinence episode, but this was not followed. Interviews with the CNA, DON, and Administrator confirmed that proper incontinence care could not be performed from behind the resident and that the resident's skin and equipment should have been cleaned. The facility's policy on perineal care emphasized cleanliness, comfort, and infection prevention, but these standards were not met during the observed care episode.