Failure to Provide Timely Incontinence Care and Maintain Infection Control
Penalty
Summary
Staff failed to provide timely and appropriate incontinence care for a resident with a history of urinary tract infection, diabetes mellitus, and hemiplegia. The resident, who required substantial to maximal assistance with toileting and was frequently incontinent, was observed wearing two saturated incontinence briefs and lying on a wet blanket used as a chux pad. The blanket was wet with urine, and dried urine was noted around the edges. During incontinence care, redness was observed on the resident's buttocks and sacral area. The CNA providing care acknowledged that the resident had not been changed in a long time and confirmed the use of two briefs, which was not in accordance with facility policy. Additionally, the CNA failed to follow proper infection control procedures by removing soiled briefs and the wet chux pad and placing them on the floor without a plastic bag. The CNA continued to touch the resident's closet door, clean bed linens, pillow, and door handle while still wearing soiled gloves, only removing the gloves after leaving the room. The DON confirmed these actions and that the resident should not have been wearing two incontinence briefs. Facility policy required proper hand hygiene and glove use after each incontinent episode, which was not followed in this instance.