F0686

D

Failure to Implement Pressure-Relief Devices and Turning Program for Two Residents With Pressure Ulcers

Alexandria, Louisiana Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide ordered pressure-relieving interventions and turning/repositioning necessary to promote healing of existing pressure ulcers and prevent further skin breakdown for two of three sampled residents. One resident, admitted with multiple comorbidities including squamous cell carcinoma of the skin, type 2 diabetes with neuropathy, peripheral arterial disease, and identified as at risk for pressure ulcers, had a documented Stage 2 pressure ulcer on the right heel. The resident’s care plan, initiated in late August 2024, included heel protectors as an intervention under a focus on safety devices and special equipment to maintain optimal functioning. Despite posted signage in the room stating the resident was to wear heel protectors, surveyor observations on multiple days and times showed the resident lying on her back in bed or sitting in a specialized wheelchair with her heels resting on the mattress and the heel protectors stored on top of the clothes closet rather than on her heels.

Across several observations, the heel protectors remained unused on top of the closet while the resident’s heels were in direct contact with the mattress, and no positioning supports were in place. A family member reported never having seen the heel protectors applied to the resident. The treatment nurse confirmed the resident had a Stage 2 pressure ulcer on the right heel that had previously been a deep tissue injury and stated that pressure reduction was one of the interventions in place to promote wound healing. An LPN later confirmed that the resident’s heel protectors were on top of the closet instead of on the resident’s heels, and acknowledged that they should have been applied as part of the wound-healing interventions.

The second resident involved had paraplegia, neuromuscular bladder dysfunction, bilateral above-the-knee amputations, and existing Stage 4 pressure ulcers on both buttocks, with documented wound measurements from a recent skin evaluation. This resident was dependent for bed mobility and transfers and was care planned for the facility’s turn and repositioning program, with a posted turn schedule indicating side-to-side repositioning every two hours. However, repeated observations over two days showed the resident in bed on his back with the head of the bed elevated, without any supportive positioning equipment in use, while two positioning wedges remained unused in a box in the corner of the room. The resident reported that staff did not turn or reposition him every two hours, that he did not refuse turning, and that no one had offered to reposition him that day. A CNA assigned to the resident stated she was familiar with his care needs but believed he was not on a turn schedule, admitted she had not turned or offered to turn him during her shift, and then acknowledged, upon review of the posted schedule, that she should have offered repositioning every two hours but did not. The DON also acknowledged the resident should have been turned or offered turning every two hours and was not.