Inadequate Infection Control During Incontinence and Bathing Care
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices during personal care and incontinence care for multiple residents. For one resident admitted with obstructive and reflux uropathy and diabetes mellitus, who was dependent on staff for ADLs, surveyors observed two CNAs transfer the resident from a geriatric chair to the bed after performing hand hygiene and donning gloves. After the transfer, one CNA, without changing gloves, retrieved towels from a cabinet, placed them on a table, checked the resident’s diaper, then accessed a body wash bottle from a drawer at the foot of the roommate’s bed. Using the same gloves, the CNA applied body wash to a wet towel, cleansed the resident’s perineal area and buttocks, applied a new diaper, and then, still without changing gloves, opened the same drawer again, touched items inside, and removed a sheet to cover the resident. A second component of the deficiency involved bathing practices for two other residents who were dependent on staff for shower/bath, toileting, and personal hygiene. For one resident with mental illness and dementia, a CNA donned PPE and brought a single basin of water mixed with body wash into the room. The CNA used one towel and the same basin of water to wash the resident’s face, chest, armpits, arms, neck, legs, perineal area, back, and buttocks, rinsing the towel in the same water between body areas, without changing the bathwater prior to providing perineal care. This sequence of care did not follow the facility’s written procedure for a bed bath, which required changing the bathwater at specified intervals, including before washing the perineal area. For another resident with epilepsy, a history of falls, and dependence on staff for shower/bath and toileting hygiene, a CNA prepared supplies, donned gloves, and brought a bucket of water into the room. The CNA used one small wet towel to clean the resident’s face, armpits, and arms, rinsing the towel in the same water between areas. The CNA then used the same water to rinse the towel, applied body wash, and cleansed the perineal area, followed by pouring water from the basin over the perineal area and drying it with a towel, and then washing the buttocks with body wash. These observed practices did not align with the facility’s bed bath policy, which directed staff to change bathwater before washing the perineal area and to wash the anal area last to avoid contamination, and also differed from referenced guidance that called for clean water or new cloths when cleaning the genital area.
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