Incomplete Perineal Care Provided to Resident with Contractures
Penalty
Summary
A deficiency was identified when a Certified Nursing Assistant (CNA) failed to provide complete perineal care to a resident with a history of muscle contractures and severely impaired cognition. During an observed wound care session, the CNA cleaned only the anal area after a bowel movement, neglecting to clean the front vaginal area as required by facility policy and professional standards. The CNA did not perform hand hygiene upon re-entering the room before donning gloves and did not follow the protocol of cleaning from front to back to avoid contamination. Interviews with the CNA, the Registered Nurse (RN) assisting with wound care, and the Director of Nursing (DON) confirmed that the perineal care was incomplete and not performed according to policy. The staff acknowledged that the resident, who was contracted and difficult to clean, did not receive care to the vaginal area, which was required. The facility's policy and staff statements indicated that the omission placed the resident at risk for complications.