F0684

D

Failure to Provide Timely Incontinence Care and Maintain Wound Hygiene

Palos Heights, Illinois Survey Completed on 03-15-2026

Penalty

No penalty information released

Summary

The facility failed to provide timely incontinence care and maintain hygiene for two residents with pressure ulcers, resulting in dried fecal matter remaining on their skin and wound dressings for over four hours. One resident was an older adult with COPD, multiple pressure ulcers to the hips, back, and sacral areas, and atrial fibrillation. The second resident was an older adult with multiple sclerosis, a stage 4 sacral pressure ulcer, major depressive disorder, and paraplegia. During wound observations conducted by the wound nurse and wound CNA late in the morning, both residents were found with large amounts of dark, crusty dried feces from a previous bowel movement on their skin and saturated onto their wound dressings, indicating the fecal matter had been present for an extended period.

In an interview, the CNA assigned to both residents confirmed she had been responsible for their care since 7:00 AM and acknowledged that she had not checked or changed either resident for incontinence because she knew the wound team was going to see them later. She admitted that neither resident had been checked or changed since at least 7:00 AM, a period of approximately 4 hours and 45 minutes. The wound nurse confirmed that although the residents’ wounds were showing signs of improvement, the presence of fecal matter on a wound dressing poses a significant risk for bacterial contamination and potential setback in wound healing. Review of the facility’s Wound Prevention and Skin Care Policy showed that staff are directed to provide timely incontinence care to maintain skin integrity and prevent contamination of existing wound sites, but this policy was not followed, resulting in a breakdown of standard hygiene protocols and compromised dignity and quality of care for the residents.