Failure to Provide Proper Incontinent Care and Prevent UTIs
Penalty
Summary
The facility failed to ensure that incontinent care was provided appropriately for two female residents who were dependent on staff for activities of daily living. In both cases, certified nursing assistants (CNAs) did not separate the residents' labia during incontinent care, which was observed by surveyors. For one resident, the CNA was about to apply a clean brief without properly cleaning the area until the surveyor intervened, at which point a brown substance was found on the wipes. The CNA acknowledged not following proper technique due to the resident's leg position and confirmed awareness of the correct procedure, which includes separating the labia and cleaning thoroughly. In the second instance, another CNA also failed to separate the labia during incontinent care for a different resident, again only correcting the technique after surveyor intervention. The CNA admitted to not following the correct procedure and recognized the importance of proper cleaning to prevent infection, rashes, and skin breakdown. Both residents were documented as requiring one or two staff for toileting assistance due to deficits in self-care performance related to medical conditions such as dementia, impaired balance, and activity intolerance. Interviews with nursing leadership, including the DON, ADON, and unit manager, confirmed that staff are trained and expected to clean female genitalia from front to back, separating the labia and using a new wipe for each area. Staff are also expected to have all necessary supplies before entering the room, change gloves as needed, and follow infection control protocols. The facility's incontinent care policy was requested by surveyors but was not provided prior to exit.