Failure to Update Care Plan with Heel Offloading Interventions
Penalty
Summary
The facility failed to update the care plan for one resident to include specific interventions for offloading her heels while in bed, despite clinical evidence and physician orders indicating the need for such measures. The resident, who had severe cognitive impairment and was at risk for pressure ulcers due to incontinence, debility, and Alzheimer's disease, returned from the hospital with a pressure injury to her heel. Although wound care orders from the hospital specified that her heels should be floated with heel protectors at all times, the care plan did not reflect this intervention for her right heel, which had a deep tissue injury. Staff interviews confirmed that the resident wore booties or pressure-reducing boots to offload her heels, but also noted that she sometimes removed them. The Director of Nursing acknowledged that the intervention should have been included in the care plan and attributed the oversight to staffing changes affecting care plan completion. Facility policies require that all relevant interventions identified in assessments be documented in the care plan and communicated to staff, but this was not done for the resident's heel offloading intervention.