F0656

J

Failure to Integrate Heel Off-Loading and Repositioning into Comprehensive Care Plan

Balch Springs, Texas Survey Completed on 03-30-2026

Penalty

Fine: $32,295

Summary

The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timeframes that reflected a resident’s identified needs for pressure injury prevention. The resident was an older female with multiple complex medical conditions, including malnutrition, COPD/asthma, toxic encephalopathy, alcohol dependence, muscle wasting and atrophy of the lower leg, cognitive communication deficit, and muscle weakness. A quarterly MDS showed severe cognitive impairment with a BIMS score of 6, total dependence for transfers and mobility, and complete bowel and bladder incontinence. The resident either refused or was unable to perform basic mobility tasks such as sit-to-lying, lying-to-sitting, sit-to-stand, transfers, and walking, placing her at high risk for pressure injuries.

The resident’s care plan, initiated for pressure ulcer risk, identified a focus of potential for development of a pressure ulcer with a goal that the resident would be free of preventable breakdown. Interventions listed included frequent checks for wetness and soiling, incontinence care every two hours as needed, scheduled bathing, and weekly skin checks with reporting of new skin conditions to the physician. However, the care plan did not include interventions for off-loading the heels or repositioning every two hours, despite the resident’s immobility and incontinence. The Braden Scale completed at admission rated the resident as low risk with a score of 16, and the facility’s documentation showed no skilled observation notes for skin assessments from early January through late February, and subsequent notes described the skin as intact with no notable changes.

Hospital documentation in the facility’s EHR from before admission showed a prevention plan that specifically ordered heel off-loading using heel protector boots or pillows lengthwise. Later, a wound care physician’s evaluation documented that the resident developed unstageable deep tissue injuries (DTIs) on both heels, and a subsequent evaluation showed an unstageable DTI on the right heel and a Stage 4 pressure wound on the left heel. Interviews indicated that the family representative had not observed heel boots or pillows under the resident’s legs until after bandages were applied, and the NP reported that the resident had been admitted without pressure ulcers or DTIs, later developed heel blisters, and that orders for off-loading and heel boots were written. The DON and ADON acknowledged that repositioning was not reflected on the TAR/MAR, that heel riser boots had not yet been received, and that the care plan lacked interventions for off-loading heels and repositioning. These documented omissions and inconsistencies in care planning and implementation led to the identified deficiency under F656 for failure to develop and implement a comprehensive person-centered care plan.