Failure to Follow Heel Offloading Orders for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and worsening of pressure ulcers by not following physician orders for heel offloading for two residents. Both residents had documented orders and care plans requiring their heels to be offloaded, either with heel protectors or pillows, to prevent skin breakdown due to their high risk for pressure injuries. Despite these orders, multiple observations over several days showed that neither resident had their heels offloaded as required. For one resident with a history of cerebral infarction, contractures, and high risk for pressure injury, the care plan and physician order specified bilateral heel offloading every shift. Observations revealed the resident lying in bed without heel protectors or pillows under the heels, and the resident confirmed that staff had not been applying the heel protectors or using pillows. Interviews with CNAs and the Restorative Nursing Assistant indicated a lack of awareness of the order and inconsistent application of the intervention, with staff stating that heel offloading had not been performed during their shifts. The second resident, who had a diagnosis including an unstageable pressure ulcer on the right heel and diabetes, also had a physician order and care plan intervention for continuous right heel offloading. Observations found the resident's right foot wrapped but not offloaded, with no heel protector or pillow in use. Staff interviews confirmed that the required offloading was not being performed, and the importance of following the order to prevent further injury was acknowledged by nursing staff. Facility policy required structured assessment and intervention for residents at risk of pressure injuries, but these were not implemented as ordered for these residents.
Plan Of Correction
Immediate Corrective Actions for resident affected by this deficient practice. On 6/12/25, DON and DSD immediately placed bilateral heel protectors for both residents 42 and 54. Plan/Process to Identify other Residents potentially affected by same deficient Practice and Corrective Action(s) to be taken; All other Residents with orders for Off-Loading heels were checked and verified by Treatment Nurse and DON on 6/12/25 and found no other deficient practices. Facility Measures and Systemic Changes to ensure the deficient practice does not reoccur. On 07/02/25, DSD and DON in-serviced all licensed Nurses regarding proper implementation of heel protectors as ordered by the physician. Starting 7/01/25, Medical Records Director will Audit daily EHR orders for heel protectors and report to the DON any deficient practice. Facility Plan to Monitor Corrective action(s); and Sustain Compliance: DON or Designee will review Performance and report to Administrator and report to QAPI monthly meetings for compliance starting 7/01/25. Monthly QA discussion will occur for 3 months.