Failure to Provide Proper Perineal Care During Incontinent Brief Change
Penalty
Summary
A resident with a history of urinary system surgery, obstructive and reflux uropathy, and ureteral calculi was admitted with bowel and bladder incontinence related to Alzheimer's disease. The admission MDS documented that the resident was always incontinent of bladder and frequently incontinent of bowel, and the care plan directed staff to wash, rinse, and dry the perineum. The facility’s perineal care policy stated that peri-care is to cleanse the perineum, eliminate odor, and prevent irritation or infection, with procedures emphasizing proper cleansing technique. During an observed incontinent brief change, one CNA removed the resident’s soiled brief, dropped it on the floor, and wiped the resident’s entire buttocks multiple times with the same wipe. The CNA then stepped away to get new gloves, and a second CNA sanitized her hands, donned gloves, and applied a clean brief without performing any peri-care or cleansing of the penis or genital area. In a subsequent interview, both CNAs stated they did not realize they were performing peri-care, believed the penis was usually cleaned during showers, and did not see any risk or negative outcomes from not cleaning the penis or peri-area. The DON stated that the penis and peri-area must be cleaned every time incontinent care is performed and that failure to provide proper incontinent care could lead to urinary tract infections, and also stated she was responsible for ensuring CNAs were trained properly but did not provide an explanation of when or how staff were trained.
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