Failure to Implement Heel Protection Leads to Unstageable Pressure Ulcer
Penalty
Summary
A resident was admitted for long-term care and identified as being at risk for developing pressure injuries, with no wounds present upon admission. Despite this risk, the facility failed to implement and document appropriate preventative measures, particularly for heel protection, after a slightly darkened area was first noted on the resident's left inner heel. There was no evidence in the medical record that the area was monitored or that interventions were put in place to prevent further skin breakdown between the initial finding and the development of an open wound. On a later date, the resident developed a new open area on the left inner heel, which progressed to an unstageable pressure ulcer as documented by both nursing staff and a wound care physician. Observations revealed that the resident did not have heel protection devices in place while in bed or in a wheelchair, and both heels were seen resting directly on hard surfaces. The care plan was not updated to include interventions for heel protection, and there were no physician's orders for pressure-relieving devices or heel offloading before or after the wound developed. Interviews with nursing staff indicated a lack of awareness and implementation of heel offloading interventions, with some staff unaware of the wound's origin or the need for specific protective measures. The wound care physician confirmed that the injury could have been prevented with timely offloading and repositioning. The director of nursing acknowledged that high-risk residents should have soft pressure-relieving devices and regular monitoring, but these measures were not documented or observed in practice for this resident.