F0686

D

Failure to Implement Individualized Pressure Injury Prevention Leading to Heel Ulcers

Carlsbad, California Survey Completed on 03-12-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to implement individualized pressure injury prevention interventions for a resident at high risk for skin breakdown, resulting in pressure injuries to both heels. The resident was admitted with a left femur fracture and required substantial to maximal assistance with bed mobility, and the MDS documented that the resident was at risk for developing pressure ulcers/injuries and had moderate cognitive impairment. The facility’s policy required repositioning all residents with or at risk of pressure injuries on an individualized schedule based on risk factors and clinical guidelines. However, the resident was placed on a standard two-hour repositioning schedule used for multiple residents, with no individualized repositioning plan despite the resident’s specific risk profile.

Staff interviews and observations showed that the resident later developed black/purple blisters on both heels, which were identified as pressure injuries that had not been present on admission. A CNA reported first noticing the heel blisters and notifying the treatment nurse, and stated that the resident frequently refused to get out of bed or be repositioned on her side. An LN confirmed that the resident was using Prevalon boots due to heel blisters caused by prolonged pressure and acknowledged that the resident had no wounds on admission. The DON stated that the resident’s fractured hip and refusals to get out of bed or be turned increased her risk and that nursing should have implemented a care plan to address these refusals. The PCP described the resident as high risk for pressure injuries and stated that, although the injuries were not entirely avoidable, the facility probably had a duty to identify the risk early and use off-loading interventions.