Failure to Implement Ordered Pressure Ulcer Interventions and Wound Care Recommendations
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer treatment and preventive care for a resident with a right heel pressure ulcer and risk for further skin breakdown. The resident had diagnoses including polyneuropathy and hypertension and had a care plan focus indicating risk for skin breakdown related to a right heel pressure ulcer, with an intervention to wear a prevalon boot to the right foot when in bed. A wound assessment dated January 15, 2026, recommended a dietitian consultation and the use of heel-float boots to both feet while in bed to offload the heels. The facility could not provide documentation that the recommended dietary consultation was requested or completed, and the most recent dietary consult in the record was from September 29, 2025. Multiple observations on February 24 and 25, 2026, showed the resident lying in bed without a heel-float boot and without pillows under the foot, despite a treatment administration record (TAR) order for right heel boots to be on at all times except during care. The resident reported that he hardly ever wore the right heel boot because staff did not place it on him and that the boot was in his closet. Review of the January 2026 TAR showed an order for Santyl ointment to the right heel daily for the pressure ulcer, but the order did not include the secondary dressings (Vashe-moistened gauze and foam) that had been recommended in the January 22, 2026 wound assessment. The February 2026 TAR documented that the resident was wearing a right heel boot every shift on the dates when surveyors observed that the boot was not in place. In an interview, the Nursing Home Administrator and DON stated they would expect the resident to be wearing the heel boot as ordered, and for wound assessment recommendations and wound orders to be correctly implemented.
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