Failure to Offload Heels for Pressure Ulcer Prevention
Penalty
Summary
Facility staff failed to implement ordered interventions to offload the heels of a resident who was at risk for pressure ulcer development and already had a pressure ulcer present. The resident, who was cognitively intact and required extensive to total assistance with mobility and activities of daily living, had a physician's order to offload heels while in bed. However, multiple observations revealed the resident lying in bed with heels resting directly on the mattress, without any offloading devices or supports in place. The resident's care plan addressed pressure ulcer prevention and treatment but did not include specific interventions for heel offloading. The resident reported that while hospitalized, staff offloaded their heels using a pillow, but this was not done at the facility. A registered nurse confirmed during wound care that the heels were not offloaded as required. Facility policy required evidence-based interventions, including heel offloading, for residents at risk or with existing pressure injuries, but these were not implemented for this resident.