Failure to Provide Adequate Perineal and Incontinent Care
Penalty
Summary
Certified Nursing Assistants (CNAs) failed to provide appropriate perineal care to a resident with a stage 4 sacral pressure ulcer and severely impaired cognition. During an observation, a CNA applied a clean brief without thoroughly cleaning the resident, as evidenced by repeated wipes that continued to show brown residue. Both the assisting CNA and the CNA performing care acknowledged that the cleaning was incomplete and that proper procedure was not followed. The Director of Nursing confirmed that perineal care should continue until the area is clean and that a clean wipe should be used each time. Further observations revealed that the resident was left heavily soiled with urine and feces, with soiled linens emitting a putrid odor. Interviews with staff confirmed that the resident was not properly cleaned and that perineal care had not been performed as scheduled. The resident, who is dependent for hygiene and toilet care, was not assigned to the CNA who provided care, and there was no documentation of refusal or reassignment. The facility's policy requires perineal care to maintain cleanliness and prevent infection, but this was not adhered to in the care of this resident.