Failure to Provide Adequate Incontinence Care and Maintain Infection Control
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to provide adequate incontinence care and did not maintain proper infection control techniques for a resident with diagnoses including major depressive disorder, dementia, COPD, and dysphagia. The resident was frequently incontinent of bladder and occasionally incontinent of bowel, requiring partial to moderate assistance with toileting. During an early morning observation, the resident was found with a wet shirt, bedsheet, and pillowcase due to urine, and had a moderate bowel movement. The CNA washed her hands and donned gloves, but after cleansing the resident's perineal area and buttocks, she continued to handle clean clothing, the resident's walker, and touched the resident's face without changing her soiled gloves. Additionally, the CNA did not clean the resident's back or head, which were also wet from the incontinence episode, before dressing him. The CNA's actions were confirmed during an interview, where she acknowledged not fully cleaning the resident or following infection control protocols. The facility's Director of Nursing also verified that the CNA did not meet expectations for cleansing the resident's upper body or maintaining infection control. Review of the facility's incontinence care policy indicated that proper hand hygiene, glove use, thorough cleansing, and changing soiled linens and clothing are required after each incontinent episode. These procedures were not followed during the observed incident.