Failure to Provide Complete and Proper Incontinent and Perineal Care
Penalty
Summary
Surveyors observed that staff failed to provide complete and proper incontinent and perineal care to three residents who required such care. In multiple instances, Certified Nursing Assistants (CNAs) did not separate the labia when cleansing female residents' perineal areas, contrary to facility policy. For one resident with a history of chronic kidney disease and urinary tract infections, the CNA cleansed the groin and peri area but did not separate the labia, despite the resident's care plan indicating a need for thorough incontinence care. Another resident, who was always incontinent and cognitively intact, also did not have the labia separated during peri care. In both cases, the care plans required incontinence care after each episode according to facility protocol. Additionally, for a third resident who was always incontinent and required extensive assistance, the CNA cleansed the rectal area and then used a clean cloth to rinse from the rectal area to the peri area, which is inconsistent with the expected front-to-back technique. Interviews with staff confirmed the expectation to cleanse from front to back and to separate the labia during care. The facility's perineal care policy specifically instructs staff to separate the labia and wash downward from front to back to prevent infection and skin irritation. These observed failures to follow established procedures led to the deficiency.