Failure to Provide Timely and Hygienic Incontinence Care
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment, who is totally dependent on staff for all activities of daily living and is always incontinent of bowel and bladder, did not receive timely and appropriate incontinence care. The resident had a recent history of urinary tract infection (UTI) and was on antibiotic and probiotic therapy. On the morning of the survey, a CNA admitted to not having changed or repositioned the resident since the start of her shift, citing being busy with another resident and the fact that the resident was asleep. The CNAs did not receive a report from the night shift regarding the last time the resident was changed. Upon assessment, the resident was found in a heavily soiled incontinence brief with evidence of prolonged exposure to urine. During the provision of care, the CNAs failed to follow proper infection control practices. After removing the soiled brief, the CNAs continued to use the same contaminated gloves to perform multiple tasks, including cleaning the resident's eyes and mouth, handling supplies, and performing peri-care. One CNA also touched various surfaces in the room with the same contaminated gloves. Both CNAs only removed their gloves and performed hand hygiene after completing all care tasks. The improper technique and lack of hand hygiene during incontinence care were acknowledged by the facility's regional RN as a breach of expected standards.