Failure to Offload Heels for Pressure Ulcer Prevention
Penalty
Summary
The facility failed to follow its own policy and physician orders regarding the prevention and treatment of pressure ulcers for a resident with a documented heel wound. The facility's wound care policy required the use of pressure-relieving surfaces and offloading of heels as preventative measures. However, review of staff training materials revealed that Certified Nursing Assistants (CNAs) were not trained on the specific policy requirements for utilizing pressure-relieving surfaces and floating heels. The resident in question was cognitively intact but required physical assistance for self-care and had a care plan and physician order in place to offload heels with a pillow while in bed. Multiple observations over several days showed that the resident's heels were consistently not offloaded as required. Instead, the heels were found resting directly on pillows or the mattress, rather than being suspended off the surface to relieve pressure. Interviews with staff confirmed a lack of understanding of proper offloading technique, as one CNA acknowledged that the resident's heels were not appropriately offloaded and that the pillow should have been positioned under the calf to keep the heel off the edge. Photographic evidence was obtained to document these findings.