Delay in Implementing Ordered Heel Protectors for Pressure Ulcer Management
Penalty
Summary
The facility failed to timely implement ordered pressure-relieving heel protectors for a resident with an existing left heel condition that progressed to an unstageable pressure ulcer. The resident, who had diagnoses including dementia and adult failure to thrive, had a skin care plan revised on 1/4/2026 indicating a left heel condition that had progressed to an unstageable ulcer on 12/24/2025, with interventions specifying that staff were to apply heel protectors to both feet while the resident was in bed. A nursing assessment dated 12/24/2025 documented that the left heel area had increased in size from 1.4 x 1.8 cm on 12/17/2025 to 2.4 x 2.9 cm, and interventions at that time included the use of heel protector boots. A physician’s order dated 12/26/2025 requested routine treatment and was addressed on 12/29/2025 with a dressing order and an instruction to apply heel protectors when the resident was not up in a wheelchair, but the treatment administration record for December 2025 showed that heel protectors were not initiated until 12/31/2025. During interview, the Clinical Support Nurse stated that the expectation was that new orders are processed as soon as possible, but at least within 24 hours, and the facility’s Prescriber Medication Order policy indicated that the nurse on duty when a new handwritten order is received is to enter it on the physician order sheet, which did not occur in a timely manner for this resident.
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