F0686

G

Failure to Implement Timely Pressure Ulcer Prevention Leading to Facility-Acquired Heel Ulcer

Keller, Texas Survey Completed on 03-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide pressure ulcer care consistent with professional standards and to prevent the development of a pressure ulcer in a resident identified as being at moderate risk. The resident was an adult male admitted after a fall at home with a left upper arm fracture, a wound to the left elbow, muscle weakness, stroke with left-sided involvement, and a history of falls. His admission MDS showed a BIMS score of 14 (cognitively intact), and his Braden Scale score was 14, indicating moderate risk for pressure ulcers. The admission assessment documented a skin issue on the right inner forearm and a fracture of the left humerus, but no heel issues were noted on admission. The care plan identified impaired physical mobility, risk of decreased tissue circulation, and an existing wound to the left elbow, and later reflected that he developed a pressure ulcer to his left heel.

During his stay, therapy records showed that the resident participated in PT, OT, and ST in the gym daily on weekdays, but otherwise he spent most of his time in bed. According to the resident’s family member, therapy staff were the only ones who got him out of bed, and staff told the family that he was too unsteady to be out of bed and that it was safer for him to remain in bed or in a wheelchair, despite his prior independence and preference for using a walker. Nursing staff interviews indicated that the resident was sometimes confused, unsteady with his walker, and was encouraged to remain in bed to prevent falls. The LVN reported that because the resident could turn himself and was getting out of bed, staff did not necessarily implement precautionary measures for pressure ulcer prevention and that she did not recall when preventive measures were initiated.

On 02/10/26, a new wound on the resident’s left heel was documented by nursing as an open blister acquired in-house, with partially intact, degloved skin. The Wound Care Nurse confirmed that the left heel wound was facility-acquired, likely related to lack of mobility and friction from the bed and sheets, and that off-loading practices such as a foam/bunny boot were not started until after the heel wound developed. Her first assessment measured the wound at 5.5 cm by 5 cm, and subsequent physician orders on 02/11/26 and 02/25/26 addressed cleansing, dressing changes, and use of a bunny boot to keep the heel off surfaces. Hospital records from a later admission documented a stage III pressure ulcer to the left heel measuring 6 cm by 6 cm. The DON and Wound Care Nurse acknowledged that heel protection was not implemented on admission because the resident was reported as ambulatory, and the DON could not confirm the accuracy of the Braden assessment without review, while the physician later stated the ulcer was unavoidable due to vascular issues and other medical problems.