F0686

D

Failure to Implement Repositioning and Offloading for Resident With MASD and Coccyx Wound

Decatur, Illinois Survey Completed on 12-10-2025

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement ordered pressure-relieving interventions and repositioning for a resident with moisture-associated skin damage (MASD) and an open coccyx wound. The facility’s pressure ulcer prevention policy requires residents to be repositioned at least every two hours in bed and every hour when in a chair. Despite this, the resident was repeatedly observed lying on his back in bed on an air mattress without pillows for offloading or side positioning, and there was no documentation of repositioning refusals. The resident, who has bilateral leg amputations, moderate cognitive impairment, and is dependent on staff for bed mobility and transfers, reported that he has sores on his buttocks that began in the hospital and that staff do not reposition him often enough or place him on his side.

Clinical documentation on the Wound Evaluation & Management Summary identified partial-thickness MASD wounds and an open area on the coccyx, with recommended interventions including offloading the wound, side-to-side positioning, and repositioning per facility protocol. CNA task charting also prompted turning and repositioning every two hours and the use of pillows for offloading. However, observations showed the resident remained on his back for extended periods in both bed and wheelchair, and CNAs acknowledged that the resident was on his back and reported he refused side-lying due to pain and removed pillows. The wound nurse stated the resident should be turned every two hours with limited sitting time, that CNAs should notify the nurse and physician and document refusals, and that behavior monitoring should be implemented, but she was unable to find any documentation of refusals of care in the medical record.