Failure to Maintain Hygienic Perineal Care Practices
Penalty
Summary
Surveyors observed that staff failed to perform perineal care in a hygienic manner for three residents who were incontinent and fully dependent on staff for toileting and hygiene. In each case, certified nurse aides (CNAs) either removed gloves and continued care with bare hands, made direct ungloved contact with residents' perineal areas, or used soiled gloves to touch environmental surfaces before continuing care. Specifically, staff were seen disposing of gloves and then making direct contact with residents' buttocks or perineal areas, and in one instance, a privacy curtain was adjusted with soiled gloves before care continued. Hand hygiene was not performed after glove removal and before further resident contact. Interviews with staff, including CNAs and an LPN, confirmed that facility expectations and checklists require glove use throughout the perineal care process. The Director of Nursing acknowledged that bare skin contact during perineal care was inappropriate. Despite requests, the facility was unable to provide a policy regarding perineal care during the survey. The residents involved were all documented as incontinent and fully dependent on staff for hygiene, as reflected in their care plans and Minimum Data Set (MDS) assessments.