F0686

D

Failure to Consistently Offload and Monitor Right Heel Pressure Ulcer

Tabor, Iowa Survey Completed on 03-04-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and to prevent further wound development for a cognitively impaired resident with an existing right heel pressure injury. The resident had severe cognitive impairment with a BIMS score of 4/15 and diagnoses including Alzheimer’s disease, non-Alzheimer’s dementia, and depression. Clinical documentation showed a history of a deep tissue injury and then an unstageable pressure ulcer on the right lateral heel, with multiple measurements recorded over several months. The care plan identified a focus on potential/actual impairment to skin integrity and referenced assistance with protective garments such as a cushion boot, and the TAR included an order for nightly Betadine treatment to the right lateral heel. However, there was at least one missed documentation entry for the ordered treatment, and wound measurements and descriptions were inconsistently documented across Skin Issues forms, Skin and Wound assessments, and progress notes.

Over time, the wound was variously described as a deep tissue injury, a Kennedy terminal ulcer/end-of-life pressure area, and an in-house acquired unstageable pressure ulcer, with differing measurements and incomplete data. For example, a Skin Issues entry on one date documented the right heel as an in-house acquired, chronic, unstageable pressure area measuring 0.75 cm by 1.16 cm with no depth, while a later Skin Issues entry documented a new right heel pressure ulcer/injury, also in-house acquired and chronic, measuring 1.5 cm by 3.5 cm with no depth and no area calculation. Several Total Body Skin assessments identified a new wound or did not identify a pressure ulcer at all and did not provide measurements. Progress notes over several months recorded varying sizes and descriptions of the right heel wound, including dark black/brown hard tissue and later a light brown scabbed area, but the documentation did not consistently align with the facility’s own protocols for weekly skin assessments with measurements and descriptive wound notes for daily dressing changes.

The facility also failed to consistently implement and monitor offloading interventions, specifically the use of a heel protector/boot to relieve pressure on the resident’s right heel. Observations on multiple days showed the resident seated in a wheelchair wearing only socks, with her feet on the footrests, while foam heel protectors or a blue foam bootie were seen on the recliner rather than on the resident. The resident was also observed in bed without a heel protector after personal care, despite a picture cue card above the bed indicating a pressure boot for the right foot. Interviews with CNAs, an RN, and the DON revealed uncertainty about whether the resident still required a heel protector, when it should be used (in bed vs. in the wheelchair), and whether there were physician orders or TAR entries for the device. Staff reported relying on a picture system on the wall to know if a resident needed a heel protector, but the DON acknowledged that the care plan and picture system did not specify when the boot should be worn and that the boot was not placed on the TAR, making it difficult to monitor its use. These actions and omissions conflicted with the facility’s policies requiring documentation of assessments, interventions, and use of pressure-relieving devices to prevent further skin breakdown.