Failure to Follow Care Plan and MD Orders for Heel Lift Boots
Penalty
Summary
The deficiency involves the facility’s failure to implement a complete care plan and follow physician’s orders for a resident who required heel lift boots while in bed. The resident’s EHR showed an admission date of 12/22/2005 and diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, and type 2 diabetes. The resident’s care plan identified a potential for skin breakdown related to decreased mobility, incontinence, and hemiplegia, with an intervention specifying heel lift boots while in bed. A physician’s order dated 03/24/2025 also directed that the resident wear heel lift boots while in bed every day shift. On multiple observations, the resident was found in bed without the ordered heel lift boots. On 02/23/2026 at 2:50 p.m., and again on 02/24/2026 at 9:11 a.m. and 10:55 a.m., the resident was observed in bed without the heel lift boots in place. When questioned, the CNA who entered the room stated she did not know the resident was supposed to have heel lift boots on and did not know where they were in the room. The LPN assigned to the resident for that shift stated she was not very familiar with the resident’s care because she was not normally assigned to that resident. After reviewing the orders, the LPN confirmed there was an order for heel lift boots while in bed and acknowledged that the resident should have been wearing them but was not.
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