Failure to Provide Clean and Safe Incontinence Care and Follow Infection Control Practices
Penalty
Summary
The deficiency involves failure to provide clean and safe incontinence and perineal care in accordance with facility policy and infection control practices for one resident. Facility policy required staff to perform hand hygiene, gather necessary supplies before care, use gloves and other PPE per standard precautions, and clean the perineal area from front to back using clean sections of the washcloth, followed by rinsing and drying. The resident involved had type 2 diabetes, needed help with personal care, was always incontinent, had a colostomy, and was at risk for repeated urinary tract infections. The care plan documented scheduled bathing and that the resident required substantial to maximal assistance with perineal hygiene. During an observed incontinence care episode, a GNA touched the bedside table, resident’s blanket, dirty linen, closet handles, and clean linen without changing gloves. The GNA handled clean towels, clean sheets, and the faucet with the same gloves used for dirty items and was unsure whether the resident remained on enhanced barrier precautions, despite the resident being on such precautions due to a colostomy. The GNA used wet towels removed from the trash bin to clean the resident’s genital area and placed used towels on clean surfaces, including a clean sheet next to the resident. The GNA continued wiping between the buttocks and washing the thighs and knees without changing gloves, and after applying prescription zinc cream, touched the bedside table with contaminated gloves. The GNA then removed gloves and gown, discarded them, left the room without performing hand hygiene, and later re-entered the room, donned gloves, and washed the resident’s face without prior handwashing. Interviews with the nurse manager and DON confirmed that staff were expected to know and follow proper incontinence care steps, including front-to-back wiping, glove changes between dirty and clean tasks, hand hygiene, and adherence to clean-to-dirty procedures.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.