Failure to Follow Perineal Care Protocol for Incontinent Resident
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to follow the facility's perineal care policy and procedures while providing care to a resident who was frequently incontinent of bladder and occasionally incontinent of bowel. The CNA used a single large wet towel to clean both the front perineal area and the anal/buttocks area, folding and reusing the same towel throughout the process. The CNA did not rinse or dry the resident's perineal area during the care. This method did not align with the facility's policy, which requires the use of separate towels with soap and water for different areas, as well as thorough rinsing and drying. The resident involved had a history of malignant neoplasm of the right breast, secondary malignant neoplasm of the brain, and was at risk for developing pressure ulcers or injuries. The resident was dependent on staff for toileting hygiene and required significant assistance with lower body dressing and toilet transfers. The incident was observed by surveyors, and during interviews, the CNA acknowledged awareness of the correct procedures but admitted to not following them during the observed care. The Director of Nursing confirmed the CNA's knowledge of the proper protocol.