F0686

G

Failure to Follow Pressure Ulcer Orders and Implement Off-Loading Interventions

Carbondale, Illinois Survey Completed on 02-10-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to follow physician orders and implement ordered pressure-injury prevention and treatment interventions for multiple residents at risk for, or with, pressure ulcers. One resident with intact cognition, decreased mobility, diabetes, incontinence, and a documented risk for pressure sores had care plan interventions for pressure reduction devices, turning and repositioning assistance, incontinence care after each episode, and ordered treatments including skin prep to bilateral heels, Triad cream and dressings to shearing on the buttocks and coccyx, antifungal powder to moisture-associated skin damage of the genital area, and off-loading boots. Despite these orders, the resident reported that staff did not reposition him in the recliner and only sometimes repositioned him in bed, especially at night only when he asked. Surveyors observed that off-loading boots were not in place on multiple occasions, and no skin prep was applied to the heels during a treatment observation. The resident was found with three open, bleeding areas on the buttocks and intergluteal cleft, consistent with stage II pressure ulcers, and with extensive redness and flaky skin over the buttocks.

During observed peri care and wound treatment for this resident, CNAs and nursing staff did not have dressings in place on the buttock wounds prior to care, and the wounds were not listed on the facility’s Wound Summary Report. The DON stated that she believed these areas were “shears” and therefore not measured or included on the wound log, and that such areas were monitored only through weekly skin notes. Weekly skin assessments documented ongoing bilateral shearing to the buttocks with bleeding at times and boggy heels with treatment applied, but the wounds were not formally entered into the wound management system until after surveyor identification. The DON also acknowledged there was no facility policy for turning and repositioning and that staff did not document turning and repositioning, instead stating they “just follow the standard” of every two hours. The resident reported not receiving showers due to the sores on his buttocks and stated he could not reposition himself in bed or chair, and that staff did not routinely reposition him in the recliner.

A second resident, cognitively intact and dependent or requiring substantial assistance for transfers and bed mobility, had documented risk for pressure ulcers, boggy heels, and physician orders and care plan interventions for skin prep to bilateral heels twice daily and off-loading boots to both lower extremities twice daily. The Wound Summary did not list this resident’s boggy heels, although progress notes documented bilateral boggy heels on several dates with sure-prep applied and no open areas. Surveyors repeatedly observed the resident without off-loading boots while in a wheelchair and in bed, with very red heels and one heel described by an RN as very soft, boggy, and non-blanchable. The resident stated that staff did not offer or attempt to apply the boots, that she could not put them on herself, and that she had only ever seen one boot, which was found in her closet; staff and the resident’s daughter reported not seeing boots in use.

A third resident with dementia, diabetes, decreased mobility, and documented unstageable pressure injuries to the left heel and buttocks had care plan and physician orders for off-loading boots twice daily, pressure-reducing devices in bed and wheelchair, and specific wound treatments to the left heel and buttocks. The facility’s Wound Summary showed an unstageable pressure ulcer to the left heel that was not present on admission and was improving in size. However, surveyors observed this resident multiple times in bed and in a wheelchair without an off-loading boot on the affected foot; at one point, the wrapped left heel was resting directly on the metal wheelchair foot pedal. The resident reported that she sat in the wheelchair all day on some days, was not repositioned in the wheelchair, and that staff did not apply a large boot to her foot. The wound clinic NP later stated that the resident had never had the off-loading boot on during clinic visits and that the resident reported staff told her she did not need it anymore, despite the NP’s belief that the boot was needed to aid healing and prevention.

Across these residents, the facility did not consistently implement or document ordered off-loading boots, heel protection, and turning/repositioning for residents at risk for or with existing pressure injuries. The DON confirmed that staff were expected to apply off-loading boots and follow physician orders but acknowledged that some residents refused and that nurses had “a lot to learn.” The physician and NP both stated they expected staff to follow orders and that off-loading boots help prevent and heal heel wounds. The facility’s Pressure Injury/Pressure Ulcer Prevention and Treatment Protocol required assessment of high- and moderate-risk residents for heel protectors and bridging of heels, yet residents with boggy heels and pressure injuries were observed without ordered off-loading devices in place, and some wounds were not entered into the wound summary for ongoing monitoring.