F0686

D

Failure to Assess, Document, and Reevaluate Treatment for a Heel Pressure Ulcer

Hermitage, Missouri Survey Completed on 03-05-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide appropriate pressure ulcer care and prevention for one resident with a right heel pressure injury, in accordance with its own wound care policy. The resident had multiple diagnoses including diabetes, depression, and edema, severe cognitive impairment, delusions and hallucinations, and was dependent on staff for all ADLs except eating. The facility’s policy required ongoing skin assessments with weekly documentation, thorough wound documentation, reevaluation of dressing and skin integrity every shift, and regular reassessment of the wound’s response to treatment. Despite this, the facility did not consistently complete or document skin and wound assessments, did not accurately reflect the resident’s wound status in routine skin assessments, and did not update treatment orders as the wound evolved.

The resident developed a right heel blister/pressure ulcer first documented in early November as an unstageable pressure ulcer measuring 4 cm by 8 cm, with subsequent documentation describing a fluid-filled blister with darkened skin and use of a protective boot and skin prep. Over November and December, wound observation reports and nursing notes showed changes in size and characteristics, including progression to 100% necrotic/eschar tissue, with measurements gradually decreasing to 3.5 cm by 4 cm. The care plan referenced a right heel blister/eschar and ongoing skin prep treatment, and the MAR reflected heel protectors and skin prep as completed. However, multiple skin assessments documented during this period and into January and February stated there were “no skin issues,” despite the ongoing presence of the right heel wound and continued treatment orders.

Beginning in January, no wound observation reports were completed for the right heel wound, and there were no progress notes related to the heel wound for that month, even though the MAR continued to show heel protectors and skin prep as administered. In February, repeated skin assessments again documented no skin issues. When surveyors observed wound care in late February, an LPN removed the resident’s sock and noted a notable odor from the foot, stating the treatment should be re-evaluated and that the odor had been present since earlier in the week. A black, round scabbed area was observed on the right heel, and skin prep was applied. A subsequent nursing note described the wound as an unstageable right heel wound with necrotic tissue, borders no longer attached, and surrounding tissue pink and warm. Interviews with nursing staff, hospice staff, the DON, NP, and the Administrator confirmed that weekly wound assessments had not been completed since December, that the wound order for skin prep had not been changed since initiation, that hospice did not share wound assessments with the facility, and that skin assessments should have included the wound but instead repeatedly documented no skin issues.

Throughout this period, the facility failed to follow its policy requirements for ongoing and weekly wound assessments, accurate documentation of wound characteristics, and timely communication and reassessment of treatment. The DON acknowledged that the former ADON had been responsible for wound assessments and that there had been no wound assessments since December, and stated he/she did not know why they were not done. The Administrator stated that staffing issues affected nurses’ completion of observations and follow-up for wounds, and that the ADON should complete weekly wound assessments and nurses should stage all wounds correctly and document monitoring of skin areas in progress notes. These actions and inactions resulted in a lack of current, accurate wound documentation, absence of documented reassessment of the wound’s response to treatment, and failure to update or reevaluate treatment orders despite ongoing necrotic tissue and later development of odor noted by staff.