F0686

G

Failure to Timely Identify and Assess Unstageable Heel Pressure Ulcer

Kettering, Ohio Survey Completed on 03-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to thoroughly assess a resident’s skin and to timely identify a pressure ulcer on the left heel, despite the resident being known to be at risk for pressure-related skin breakdown. The resident was admitted without pressure ulcers and with no history of skin integrity issues, and an initial Braden Scale assessment identified a moderate risk for pressure sores. Physician orders at admission included weekly skin assessments and use of a pressure-reducing mattress, and later orders added bilateral heel cleansing and skin prep every shift as a preventive measure. Weekly skin assessments and multiple bathing/skin documentation entries over several weeks consistently recorded only soft, blanchable heels or blanchable redness to the heels, with no open areas or wounds documented.

In the weeks leading up to the discovery of the wound, weekly skin assessments dated 11/25, 12/02, 12/06, and 12/12 documented no open areas on the left heel, and bathing documentation on multiple dates recorded only blanchable redness to the bilateral heels and no additional skin issues. Preventive heel care ordered on 11/24 was documented on the Treatment Administration Record as being completed twice daily on several dates. However, on the same day that a bathing sheet documented no wounds or skin integrity issues on the left heel, a late-entry nursing note recorded that an open area on the left heel with slight drainage was identified, measuring 4.5 cm by 3 cm by 0.1 cm. A weekly skin assessment and a skin breakdown assessment completed the following day documented the same open area and measurements, and a subsequent wound evaluation identified the wound as an in-house acquired unstageable pressure ulcer with 90% necrotic tissue and 10% granulation tissue.

The wound nurse later stated that the left heel wound was discovered during a facility-wide skin sweep initiated because of an increase in self-reported incidents and wounds, and that she had started daily skin sweeps in the memory care unit. She also stated that the resident had no wound NP visits during two earlier weeks because a previous skin issue at a different site had resolved. The wound NP confirmed that the resident developed an in-house unstageable pressure ulcer to the left heel identified by staff. The facility’s wound management policy required accurate documentation of treatments and focused wound assessments weekly and as needed with changes in condition, and NPIAP guidelines cited by surveyors emphasized comprehensive, ongoing skin assessment, including head-to-toe inspection with particular focus on bony prominences such as heels and the use of each repositioning opportunity to assess skin. Despite these requirements and guidelines, the resident’s left heel pressure injury was not identified until it had progressed to an unstageable pressure ulcer.