Failure to Implement Ordered Heel Offloading for Resident With Stage 3 Pressure Ulcer
Penalty
Summary
The facility failed to provide ordered pressure ulcer treatment and preventive services for a resident with an existing right heel pressure ulcer. The resident was admitted with a right heel pressure ulcer and diagnoses including a left pubis fracture, type 2 diabetes mellitus with diabetic neuropathy and hyperglycemia, and severe protein-calorie malnutrition. An admission nursing note documented the presence of the right heel pressure ulcer, and a medical progress note directed staff to offload the right heel continuously with boots and pillows and avoid pressure on the affected area. A subsequent skin and wound note identified the right heel ulcer as Stage 3 and recommended floating the heels while in bed using pillows or boots and ongoing pressure reduction and turning/repositioning precautions per protocol. The January Treatment Administration Record contained a physician’s order to offload heels with green boots as tolerated every shift, and documentation showed the boots were signed off as worn each shift on 1/28/26. Despite these orders and documentation, multiple observations on 1/29/26 showed the resident’s heels were not offloaded as ordered. During the first observation, the resident was in bed on his/her back eating breakfast with both feet lying directly on the mattress, wearing gray slipper socks and no heel boots. When asked, the resident stated that staff sometimes elevated his/her feet but that there was nothing in place at that time. A second observation later that morning again showed the heels resting directly on the mattress without heel boots. A third observation showed a pillow under the bottom of the resident’s legs, with the resident still wearing gray slipper socks and no heel boots present. The DON, upon observing the resident and being informed that staff had been signing off that heel boots were being worn despite no heel boots being in the room, confirmed the finding.
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