Failure to Prevent Development of Avoidable Pressure Ulcer
Penalty
Summary
A resident was re-admitted to the facility with a diabetic foot ulcer on the left heel, but there was no documentation of any wound on the right heel at the time of admission. The resident's care plan included interventions for skin integrity, such as the use of an air mattress, but did not specify protective measures for the right heel. On a later date, nursing staff observed blood on the resident's right sock and identified an open area on the right heel, described as a 5x5 cm broken blister with red inner tissue, white soft tissue, and dark pink edges. The supervisor and family were notified, and the resident was transferred to the hospital the same day. Upon return, the right heel wound was documented as a Stage 2 pressure ulcer. The care plan was not updated to include specific interventions for the right heel until after the pressure ulcer had developed. Prior to the identification of the right heel wound, there were no documented interventions to protect the right heel from pressure ulcers. The Director of Nursing confirmed that the right heel wound developed in the facility and that protective measures for the right heel were not implemented until after the wound was discovered.