Failure to Timely Assess and Protect Heels Resulting in Worsening Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and thorough pressure ulcer care and prevention for a resident at risk for skin breakdown, resulting in a right heel pressure ulcer that progressed to Stage IV. The resident was admitted with multiple medical diagnoses, was moderately cognitively impaired, and was dependent on staff for all ADLs including bed mobility and transfers. A pressure risk assessment identified the resident as at risk for developing pressure ulcers. On 2/4/25, nursing documentation identified new open areas on the right heel with black tissue, bloody drainage, red wound edges, and edema. A skin-only evaluation the same day documented two open areas on the right heel with necrotic tissue and bloody drainage, and noted redness on the left heel without measurements or further assessment. Despite these findings and the resident’s immobility and preference to lie on her back with heels resting directly on the bed, heel protectors were not obtained upon admission. The record further shows that a wound care referral was not documented until 2/13/25, when a wound physician was notified and orders were obtained for a heel guard and wound supplements for a right heel Stage III pressure ulcer. There is no documentation of a full wound assessment of the right heel upon the resident’s return from the hospital on 2/13/25, despite facility policy requiring a complete description of pressure ulcers and examination of the skin of newly admitted residents. When the wound physician evaluated the resident on 2/20/25, the right heel ulcer was documented as a Stage IV pressure ulcer measuring 4.0 cm by 3.0 cm by 0.2 cm. Staff interviews confirmed that the wound appeared worse on 2/20/25 than when the resident returned from the hospital, that the wound had been identified as facility-acquired, that the resident’s heels had been resting directly on the bed most of the day, and that the facility could not provide documentation of a right heel wound assessment upon readmission.
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