Long-Term Care Survey Alert

Here's what surveyors will expect to see.

Heels up, nursing homes:
Surveyors will be honing in on residents' feet under the revised F314 tag for pressure ulcers.

While most decubiti occur on the sacrum, they are occurring more frequently on residents' heels, are hard to assess  and heal - and require early identification, warns the Centers for Medicare & Medicaid Services in revised survey guidance for pressure ulcers that went into effect Nov. 12, 2004.

Follow these expert care tips to keep residents' heels healthy - or to heal skin breakdown.

1. Use positioning techniques to keep the resident's heels off the bed. The F314 guidance suggests using pillows to support the entire lower leg as a method to keep the heels off the bed (taking into consideration the resident's other conditions), but advises against using donut-shaped cushions.

Problem: Care planning to keep a resident's heels off the bed is one thing - but actually doing it consistently is another matter entirely.

Solution: Get all team members (nursing, activities, social service, the QA and staff development teams) to check residents often to make sure the heels are off loaded, suggests Norma Jean LaPoint, RN, MDS coordinator for United Helpers Nursing Home in Ogensburg NY. "Especially focus on those residents who tend to move around a lot and whose heels come off the pillow as a result."

Tip: "Raising the foot of a hospital-type bed to elevate the legs at intervals can take pressure off the heels and aid circulation," says Nathan Lake, RN, an MDS expert in Seattle.

Survey tip: When the care plan says staff will keep a resident's heels off the bed, expect surveyors to check to see whether that intervention is in place, warned Courtney Lyder, ND, speaking at a recent National Association of Post Acute Care conference in Washington, DC.

2. Incorporate heel checks into QA audits. That's the tack used by Broadview Multi-Care Center Rosepoint Pavilion in Parma, OH. "We do a QA audit on all three shifts to see if residents' heels are off the bed. Then we share the findings of the audits weekly with managers and monthly with the nurses at the staff meeting," reports DON Lisa Conrad, RN.

3. Evaluate and individualize use of various devices to reduce or relieve pressure on the heels. Heel lifts can provide pressure relief, says LaPoint, "but they are bulky and you have to consider each resident individually for their quality of life," she adds.

Clinical tip: Monitor heel lifts closely as these may cause pressure in other areas, especially in residents who have edema, LaPoint cautions.