F0677

D

Incomplete Perineal Care After Incontinence for Two Dependent Residents

Dubuque, Iowa Survey Completed on 02-12-2026

Penalty

No penalty information released

Summary

Surveyors identified a deficiency in the provision of complete perineal care after incontinence for two residents who were always incontinent of bowel and bladder and dependent on staff for toileting hygiene and transfers. Resident #11 had severe cognitive impairment, hypertension, diabetes, anxiety disorder, and depression, and a care plan directing frequent incontinence care with barrier ointment. During observed care, two CNAs used a limited number of washcloths, did not separate skin folds while cleansing the perineum, reused the same surface of a washcloth across multiple areas, and failed to wash the hip areas and the right buttock before applying a clean brief. This care did not include washing all areas that came into contact with urine or stool, including abdominal folds, buttocks, and hips, as described by facility staff expectations and the facility’s incontinent care checklist.

Resident #84 had dementia, anxiety, severely impaired cognitive skills for decision making, and was always incontinent of bowel and bladder, with a care plan requiring routine and as-needed incontinence care and assistance with post-toileting hygiene. Surveyors observed a heavily soaked brief being removed, described as making a “plop” noise when it hit the trash can, indicating it was very wet. During subsequent care, a CNA used a wipe to swipe the rectal area one time and did not wash the front perineal area or the buttocks before standing the resident with a stand lift. Staff interviews confirmed that all skin areas exposed to urine should be washed front to back, using a clean surface of the cloth with each stroke, and that the front perineal area had not been cleansed for this resident during the observed episode.