Failure to Implement Heel Protectors for Resident with Skin Impairment Risk
Penalty
Summary
The facility failed to adhere to its plan of care for a resident with a potential for skin impairment, specifically regarding the use of heel protectors. The resident, who has a history of a stage 4 pressure ulcer on the right heel and other conditions such as fragile skin, limited mobility, and edema, was observed without heel protectors while in a wheelchair. The plan of care required the use of bilateral heel protectors when the resident was in the wheelchair, initiated in July 2024. However, during observations on April 2 and April 4, 2025, the resident was seen without the required heel protectors. A CNA confirmed that the resident did not wear heel protectors in the wheelchair and that there were no heel protectors in the resident's room.