Failure to Implement Care Plan Interventions for Heel Boots
Penalty
Summary
A deficiency occurred when the facility failed to implement care plan interventions for the use of heel boots for a resident identified as being at risk for impaired skin integrity. Despite a care plan dated 06/04/25 specifying the use of Prevalon style off-loading boots to both lower extremities while in bed, multiple observations over several days showed the resident in bed or in a recliner without heel boots in place and with heels resting directly on surfaces. No extra pillows or heel boots were observed at the bedside, and the boots were later found stored in a closet. The resident, who had diagnoses including muscle weakness, high blood pressure, and difficulty walking, required substantial assistance for transfers and lower body dressing, and was dependent on staff for these activities. Record review and staff interviews revealed that although there was an order for heel boots, the intervention was not entered into the care plan or the CNA Kardex, and there was no documentation of the resident refusing the intervention. The resident and their family reported that the boots had not been used for some time, despite being present daily. The facility's policy requires that comprehensive care plans include measurable objectives and interventions to meet residents' needs, but in this case, the required intervention for heel boots was not implemented or documented.