Inappropriate Infection Control During Incontinence Care
Penalty
Summary
During an observation of incontinence care, a Certified Nursing Assistant (CNA) provided care to a resident with multiple diagnoses, including malignant neoplasm of the colon, duodenal ulcer, dementia, urinary retention, depression, chronic pain syndrome, gastritis, and moderate protein-calorie malnutrition. The CNA used two washcloths and a bath towel to perform perineal and rectal care. After washing the resident's perineal and rectal area, the CNA continued to use a visibly soiled washcloth, using a different part of the same cloth, and placed the soiled washcloth on a clean towel. The CNA then dried the resident with the towel that had come into contact with the contaminated washcloth. The CNA proceeded to wipe the resident from the perineal area to the rectum with the same soiled washcloth, and upon noticing additional feces, used tissues from the bedside stand to clean the area. The CNA then continued to use the feces-soiled washcloth to wipe the resident two more times before being stopped by the surveyor, who instructed her to obtain a clean washcloth. The CNA confirmed in an interview that she had used a feces-soiled washcloth during the care. Facility policy on perineal care requires cleanliness to prevent infection and skin irritation, which was not followed in this instance.