F0690

D

Failure to Provide Timely and Proper Incontinent Care and Pericare, Increasing UTI Risk

Texarkana, Texas Survey Completed on 02-26-2026

Penalty

Fine: $31,440

Summary

The deficiency involves the facility’s failure to provide timely and appropriate incontinent and perineal care to a female resident who was incontinent of bowel and bladder. The resident, an older adult with heart failure, obesity, and hypothyroidism, had an annual MDS showing a BIMS score of 14, indicating no cognitive impairment, and required dependent assistance with ADLs. ADL documentation for January and February 2026 showed very low recorded frequencies of incontinent care on day and evening shifts. The resident reported she was typically cleaned only once per shift and stated that on two occasions in the month she went more than an entire day without being cleaned. She also reported that CNAs placed blankets under her to catch urine and keep the sheets dry, and that she had contacted the Ombudsman after feeling the Social Worker and DON were not resolving her concerns.

During an observed episode of perineal care, two CNAs entered the resident’s room to perform care. One CNA washed her hands only before starting care and not again until leaving the room, while the other did not wash hands before beginning care. One CNA stated she did not have hand sanitizer and that the facility did not provide it, and proceeded with care as usual. When the resident’s brief was removed, it was completely saturated, urine leaked onto the sheets, and there was a strong ammonia odor. The CNA stated it was the first time she had touched the resident that day, and the resident stated it was the first time she had been changed since around 2:00 a.m., reporting soreness of her thighs, buttocks, and vagina from being wet for a prolonged period. The CNA noted that blankets under the resident had likely been placed by night shift.

During the same care episode, the CNA changed gloves without washing hands and continued incontinent care. She wiped from the top of the buttocks toward the vagina four times using the same wipe, with BM noted on the wipe when discarded, contrary to the facility’s perineal care policy, which directs wiping from vagina toward anus for females and discarding the washcloth after each stroke. In a subsequent interview, the CNA acknowledged she had not performed pericare correctly, citing lack of hand sanitizer and recognizing that wiping from back to front could cause infection. She also stated there was not enough staff to keep all residents clean and dry. The DON stated that hand hygiene and proper wiping technique were expected to prevent introducing bacteria to the urinary tract and that there were two CNAs on the hall with no reason for unreasonable delays in care, while also acknowledging a facility-wide problem with documentation. The Administrator stated she expected perineal care to be done “by the book,” timely and with infection-prevention techniques, and indicated she was unaware of the resident’s care problems because no grievance had been written despite the resident’s complaints.