Improper Perineal Care and Infection Control Practices
Penalty
Summary
Facility staff failed to provide appropriate perineal care to residents who were incontinent of bowel and/or bladder, as observed in three sampled residents. The facility's policy required perineal care to be performed at least daily and as needed, using clean soapy washcloths or wipes, moving from front to back, and using a clean area of the washcloth or a new wipe for each stroke. However, observations revealed that staff repeatedly used the same soiled wipe to clean multiple areas of the perineal region, rather than discarding wipes after a single use. In some cases, staff also failed to change gloves after providing perineal care and before applying a new incontinent brief, contrary to facility policy and standard infection control practices. The residents involved were dependent on staff for personal care and hygiene, with medical histories including frequent or occasional incontinence, cognitive impairment, and recent or ongoing treatment for urinary tract infections. Staff interviews confirmed improper perineal care techniques, such as reusing wipes and not changing gloves, while other staff and the Director of Nursing stated that wipes should be used once and gloves changed after care. These actions and inactions resulted in a failure to provide appropriate care and services to prevent urinary tract infections and to restore continence to the extent possible.