Failure to Assess and Treat Bilateral Heel Pressure Ulcers
Penalty
Summary
The facility failed to provide appropriate assessment, documentation, and treatment for pressure ulcers on the bilateral heels of a resident with a complex medical history, including diabetes, a stage 4 sacral pressure ulcer, and previous lower extremity amputations. Upon admission and subsequent readmissions, the resident was noted to have pressure ulcers on both heels, but the facility's documentation lacked essential details such as wound stage, measurements, descriptions, and specific treatments. The care plans and treatment administration records grouped multiple wounds together under generalized treatment orders, rather than specifying individualized care for each wound as required by facility policy and professional standards. Despite hospital discharge summaries providing clear instructions for wound care, including the use of specific dressings and follow-up with a podiatrist, the facility did not update treatment orders to reflect these recommendations. There was no evidence that the wounds on the heels were properly assessed or that the recommended treatments were implemented. The wound physician consultant did not review the heel ulcers, and the nursing staff focused primarily on the sacral wound, neglecting the bilateral heel ulcers. Interviews with staff revealed a lack of awareness and oversight regarding the presence and severity of the heel wounds, and the documentation remained incomplete or inaccurate throughout the resident's stay. Direct observation by the surveyor, DON, and wound nurse confirmed the presence of significant pressure ulcers on both heels, with one being unstageable due to necrotic tissue and the other a stage 3 ulcer with slough. Staff interviews further indicated that wound assessments and documentation were not consistently performed, and treatment orders were not individualized or updated as needed. The facility's failure to assess, document, and treat the resident's heel pressure ulcers in accordance with professional standards resulted in a deficiency in pressure ulcer care.