F0686

D

Failure to Provide Timely Turning and Incontinence Care for High-Risk Resident

Belleville, Illinois Survey Completed on 03-27-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide timely turning/repositioning and incontinence care to prevent the worsening and development of pressure ulcers for one resident at very high risk. The resident had diagnoses including a stage 4 sacral pressure ulcer, osteoarthritis of both hands, and peripheral vascular disease, and was dependent on staff for all ADLs with continuous bowel and bladder incontinence. Her care plan identified impaired skin integrity related to a coccyx pressure injury, pain, incontinence, decreased mobility, and poor circulation, and noted that she sometimes refused repositioning. Interventions in the care plan and physician orders included assistance with turning/repositioning at least every two hours, application of moisture barrier with each incontinent episode, floating heels, use of heel protectors, and specific daily wound care and dressing changes for the coccyx wound, with ongoing monitoring and documentation of wound characteristics.

Despite these identified needs and interventions, observations over several hours showed the resident sitting in her wheelchair without any repositioning or incontinence checks. The resident reported that she did not have a pressure ulcer before admission and stated that staff did not check, change, or turn her every two hours. A CNA acknowledged that residents should be turned, repositioned, and changed every two hours but reported difficulty completing rounds due to feeling there was not enough staff. The ADON and Infection Preventionist both stated they expected residents to be checked, changed, and repositioned at least every two hours, and the ADON reported there was no formal turning and repositioning policy, only a general protocol to turn residents with wounds every two hours to relieve pressure.