F0686

D

Failure to Notify Physician and Dietician and to Follow Wound Protocols for Heel Pressure Ulcer

Waynesboro, Pennsylvania Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary treatment and services, consistent with professional standards and facility policy, for a resident with a left heel pressure ulcer. Facility policy required an RN to assess, document, and notify the physician of a new pressure injury by the end of the following shift and to consult the dietician for all residents at risk for or with skin breakdown. The policy also specified that intact black heels without signs of infection should be treated with pressure redistribution, heel floating, and protective barrier, with no dressing necessary. The resident had diagnoses including an unstageable pressure ulcer of the left heel, Alzheimer’s disease, and Type II diabetes with polyneuropathy.

On a skin check dated August 19, 2025, nursing staff identified a new in-house acquired unstageable pressure ulcer on the resident’s left posterior heel, measuring 1 cm by 1 cm with a dry scabbed area and normal surrounding skin. The clinical suggestion to notify the provider for a new onset or worsening condition was not selected on the skin check form, and the corresponding progress note did not document physician notification. The RN cleansed the area with povidone iodine, applied no dressing, removed shoes that appeared too small, placed slipper socks, and documented that pressure would be offloaded, but this treatment was not ordered by the physician nor part of physician-approved wound protocols. A weekly skin evaluation ordered for the resident was not completed on August 22, 2025, with documentation that the LPN was unable to complete it due to time.

On August 29, 2025, another skin check documented a new unstageable pressure ulcer on the same left heel, again 1 cm by 1 cm with 100% eschar, and again the suggestion to notify the provider was not selected and the progress note did not show physician notification. On September 4, 2025, after a fall, the resident complained of discomfort to the left heel, and assessment revealed an open wound measuring 1.5 cm by 1.5 cm with a pink moist center; the area was cleansed, collagen applied, and covered with a silicone dressing, and the physician was notified of the fall and resulting open wound, leading to a treatment order that same day. A dietician note dated October 13, 2025, referenced an unstageable pressure injury to the left heel based on an October 9 skin check and recommended a protein supplement, but there was no documentation that nursing staff had notified the dietician of the pressure ulcer between August 19 and October 13, 2025. In an interview, the Nursing Home Administrator confirmed that nursing staff should have notified the physician and dietician when the pressure ulcer was first identified and that the RN had applied a treatment not ordered by the physician or included in approved wound protocols.