Incomplete Incontinence Care and Infection Control Lapses
Penalty
Summary
Staff failed to provide complete and appropriate incontinence care for a resident with severe cognitive impairment and multiple diagnoses, including stroke and dementia. During observed care, staff performed some steps of perineal care according to policy, such as hand hygiene and use of gloves, but did not fully cleanse the entire surface area of the resident's buttocks. Additionally, one staff member used different areas of the same cleansing wipe to clean the buttocks, rather than using a new wipe as required by facility policy. Another staff member failed to perform hand hygiene after removing gloves and before donning new gloves to apply a clean brief. Facility policy specifies the use of separate wipes for different areas during perineal care and emphasizes thorough cleansing to prevent infections and skin irritation. The Regional Nurse Consultant confirmed that staff are expected to use a different wipe for the groin, front perineal, penis, and urethral areas. The observed deviations from policy during incontinence care did not align with these requirements, resulting in incomplete care and a failure to follow established infection prevention protocols.