F0686

G

Failure to Implement Ordered Heel Offloading and Repositioning for Resident With Unstageable Heel Ulcer

Milbank, South Dakota Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement and follow pressure ulcer prevention and treatment interventions for a resident with an existing unstageable pressure ulcer on the left heel and identified risk for pressure injury. The resident had multiple sclerosis, was non-ambulatory and confined to bed or chair, and had Braden scores of 16–17 indicating mild risk. Her care plan, initiated 12/9/25, documented fragile skin, an existing unstageable left heel pressure injury, and directed staff to reposition her at least every hour when in a chair and every two hours at night in bed, and to use pressure-reducing devices including an air mattress, wheelchair/recliner cushion, and heel boots to the left foot as needed. Physician orders included daily wound cleansing and moisturizing cream to the left heel and an order from 8/2/22 for heel boots to be placed every morning, afternoon, and night shift.

Surveyor observations over multiple days showed the resident repeatedly seated or lying without heel boots or other heel offloading while remaining in the same position for extended periods. On several occasions, she was observed in her wheelchair or recliner for hours without heel boots, and at one point lying in bed on her back with no heel boots or pillows to offload her heels, remaining in the same position for approximately two and a half hours. During a wound care observation, the DON and wound nurse removed the heel boot to perform care and did not reapply it afterward. Staff interviews confirmed that the wound nurse had instructed staff to leave the heel wound open to air and use a heel boot for cushioning, but this was not consistently done.

Additional interviews and record review revealed systemic gaps in communicating and implementing the resident’s pressure ulcer interventions. CNAs and a medication aide reported relying on CNA sheets for direction on repositioning and use of pressure-relieving devices. The CNA sheet for this resident did not include her specific pressure ulcer interventions, such as hourly repositioning in a chair or the need for heel boots, and only directed staff to monitor skin, lay her down after meals, use an air mattress, and place a cushion in her chair. One CNA stated she only applied heel boots when the resident was in her wheelchair and did not understand the need for them in bed or a recliner. The DON acknowledged that the resident’s heel ulcer began as a blister associated with ACE wrap use for edema and stated that residents should ideally be repositioned every two hours, also acknowledging that the care plan directive for hourly repositioning in a chair was not being followed and that care plans should reflect current care needs.