F0686

G

Failure to Monitor Offloading Boots and Prevent New Pressure Ulcer

Manchester, Connecticut Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate pressure ulcer prevention and monitoring for a dependent resident at high risk for skin breakdown. The resident had multiple diagnoses including dementia, Parkinson’s disease, CKD stage 3, hypothyroidism, protein-calorie malnutrition, and type 2 diabetes, and was dependent on staff for personal hygiene, bed mobility, and transfers. A quarterly MDS documented severely impaired cognition and three unhealed stage 4 pressure ulcers present on admission, and the care plan identified impaired skin integrity with interventions such as turning and repositioning every two hours, use of a low air-loss mattress, and offloading heels as tolerated. A Braden Scale assessment identified the resident as high risk for pressure injuries, and a wound care note documented that a prior left medial foot wound had resolved.

Despite these identified risks and care plan interventions, the clinical record from mid-May through late September did not contain any physician order to utilize offloading boots or to check the skin under the boots every shift. A weekly skin check on 9/21/25 documented no new skin issues. On 9/23/25, an APRN was asked to evaluate a wound on the resident’s left foot and documented a left dorsal foot wound requiring daily cleansing and silver alginate dressing. Later that day, the ADON documented discovering an open area on the left dorsal foot, approximately 3 cm by 0.5 cm, and attributed it to the resident’s skin rubbing against the strap of the offloading booties. The ADON noted that the offloading boots were removed and replaced, and that new dressing orders were obtained, but there was no prior order directing use of the boots or skin checks under them.

On 9/25/25, the wound care physician documented a new full-thickness wound on the left dorsal foot measuring 1.1 cm by 0.9 cm by 0 cm with 100% slough and moderate serosanguinous drainage, and recommended offloading heels per facility protocol. A later note on 3/19/26 showed the left dorsal foot wound persisted as a stage 4 pressure ulcer. Interviews with the APRN, the wound care physician, and the ADON indicated that the wound was not identified timely, that the resident should have had an order to offload both heels while in bed, and that offloading boots, once used, should have been removed every shift to assess the underlying skin. They stated that if the skin under the boots had been assessed every shift, the area could have been identified earlier and the progression to a full-thickness wound might have been prevented or less severe. The facility’s pressure injury policy referenced systematic prevention and management based on risk factors such as impaired mobility, comorbidities, cognitive impairment, and malnutrition, but there was no available policy specific to offloading boots.