F0686

G

Failure to Implement and Timely Manage Heel Pressure Ulcer Interventions and Treatments

Moline, Illinois Survey Completed on 03-17-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to prevent and properly manage pressure ulcers for a resident with multiple comorbidities, including existing Stage 4 heel ulcers, edema, reduced mobility, and fragile skin. The resident’s care plan identified risk for impaired skin integrity due to fragile skin, bilateral lower extremity edema, reduced mobility, and an indwelling urinary catheter, but physician orders to float the heels and apply foam boots to offload pressure were never incorporated into the care plan. The resident developed in-house acquired blisters on both heels that progressed to pressure ulcers, with the right heel documented as Stage 4 and the left heel as Stage 2 by the nurse practitioner. The wound care nurse later stated that the heel wounds were caused by pressure from the bed’s footboard, which was not long enough, allowing the resident’s heels to press against it.

The facility failed to assess and document the new heel wounds in a timely manner and did not promptly implement appropriate wound care interventions. The wound care nurse acknowledged that the heel wounds were first identified by a floor nurse on one date, but her first formal wound assessment was not completed until several days later, instead of the following day as she stated should occur. During this period, interventions such as padded booties and a bed extender were only implemented after the pressure injuries had already developed. Additionally, the wound care physician’s initial evaluation documented a Stage 4 right heel pressure injury and a Stage 2 left heel pressure injury that had been present for more than one day, and debridement of the right heel revealed deep tissue involvement at the muscle/fascia level.

The facility also failed to implement the wound care physician’s ordered treatment regimen for the right heel. The physician ordered Leptospermum honey with a gauze island border dressing for the right heel wound, but this order was not entered into the physician orders, MAR, or TAR. Instead, the resident’s orders and MAR reflected a different treatment using normal saline or wound wash followed by xeroform gauze and bordered gauze. The wound care nurse admitted that it was her responsibility to enter new wound treatment orders into the electronic medical record the same day they were ordered and acknowledged that the physician’s treatment recommendation for the right heel was not implemented. Subsequent wound evaluations showed the left heel wound progressed to unstageable necrosis and, after debridement, was revealed to be a Stage 4 pressure injury, while the right heel remained a Stage 4 pressure wound. The resident was later hospitalized with sepsis secondary to UTI and wound infection, with imaging and operative findings indicating severe bilateral heel ulcerations and osteomyelitis, and cultures growing multiple resistant organisms from the heel wounds.