F0686

D

Failure to Follow Pressure Ulcer Treatment Orders and Heel Offloading Interventions

Munster, Indiana Survey Completed on 01-28-2026

Penalty

No penalty information released

Summary

The deficiency involves failure to follow ordered pressure ulcer treatment for one resident and failure to implement ordered heel offloading interventions for another resident. For one resident with diagnoses including a left humerus fracture and cellulitis of the left lower extremity, surveyors observed wound care to a small sacral pressure ulcer measuring approximately 0.5 cm. The physician’s order directed staff to cleanse the sacrum with normal saline and/or wound cleanser, apply skin prep to the surrounding skin, and cover with a hydrocolloid dressing. During the observed dressing change, the wound nurse cleansed the area with normal saline, patted it dry, and applied a hydrocolloid dressing, but did not apply the ordered skin prep. In a subsequent interview, the wound nurse confirmed that she had not applied the skin prep as ordered.

The deficiency also includes failure to ensure heel offloading for another resident with a sacral/buttocks pressure ulcer and diagnoses including multiple sclerosis, cerebral infarction, and peripheral vascular disease. This resident was observed in bed on two occasions with a standard mattress and padded overlay, but without any pillow or padded boots in place to offload the heels; the resident’s feet were resting directly on the mattress. The resident’s MDS indicated cognitive intactness, bilateral range of motion impairment, and dependence for toileting and transfers. A physician’s order directed that the resident’s heels be suspended or offloaded while in bed. During an interview, the Unit 2 Manager acknowledged that the resident’s heels were not offloaded, stating that the resident did not like to wear the boots but that there should have been a pillow in place for offloading.