Failure to Offload Heels and Maintain Ordered Dressings for Pressure Injuries
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary pressure ulcer care and preventive measures for two residents with existing pressure injuries and identified risk. For one resident with severe cognitive impairment and dependence for all footwear tasks, surveyors observed on multiple occasions that the resident was seated in a reclining chair with direct pressure on the coccyx and both heels resting on the leg rest, without heel offloading or a pressure-reducing pad in the chair. The wound nurse confirmed the resident had a Stage 4 pressure ulcer and an unstageable pressure ulcer on the left heel and two unstageable pressure ulcers on the right heel, and stated the resident should wear pressure-reducing heel boots in bed and in the chair. The LPN reported the pressure reduction boots were in the closet, and the physician’s orders and care plan both directed that the heels be offloaded with heel boot protectors or pillows. The facility’s skin management policy did not include guidance for offloading pressure ulcers. For a second resident admitted with multiple diagnoses and assessed as at risk for pressure injuries, orders were in place for daily wound treatments to a sacral wound and a left great toe wound. During incontinence care, surveyors observed a large sacral wound with a dark central area and red surrounding tissue, with no dressing in place; the CNA stated she did not know when the dressing came off. Later, the wound nurse assessed the resident, who exhibited pain responses during sacral wound care, and confirmed an unstageable wound on the left great toe, also without a dressing in place, while the resident’s heels were directly on the bed. Wound documentation showed a Stage 3 sacral pressure injury measuring 10 cm by 10 cm and an unstageable pressure injury on the left big toe. The DON stated that treatments to pressure injuries are intended to add protection and that he expects treatments to be in place, and the facility’s skin management policy emphasized the need for a system to assure consistent implementation of monitoring and documentation protocols.
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