Failure to Provide Timely Incontinence Care and Adhere to Infection Control During Perineal Care
Penalty
Summary
Facility staff failed to provide timely and appropriate incontinence and perineal care to two residents who were unable to perform their own activities of daily living. Both residents were observed to have a noticeable odor of urine and were found in heavily urine-soaked briefs and clothing. Staff did not check or change these residents at least every two hours as required by the care plans and facility policy, resulting in prolonged exposure to moisture and soiled garments. Direct observations revealed that certified nursing assistants (CNAs) did not follow proper infection control procedures during perineal care. Staff were seen donning gloves without sanitizing their hands, failing to change gloves and sanitize hands when moving from dirty to clean tasks, and applying barrier creams with soiled gloves. In some instances, staff left the resident’s room with dirty gloves and linens, further breaching infection prevention protocols. The perineal care provided did not include thorough cleaning of all areas exposed to urine, such as the genitals, buttocks, and thighs, as required by facility policy and in-service training. The residents involved had significant medical histories, including severe cognitive impairment, mobility deficits, incontinence, and risk factors for pressure ulcers and skin damage. One resident was dependent on staff for all ADLs and had existing moisture-associated skin damage, while the other required maximum assistance and was at risk for pressure ulcers. Staff interviews confirmed that care was not provided as frequently as required, and that infection control practices were not consistently followed, placing residents at risk for further skin breakdown and infection.