LOS ANGELES, CA - A recent state inspection at The Rehabilitation Center On Pico revealed serious deficiencies in pressure ulcer prevention that resulted in a vulnerable resident developing a potentially dangerous heel injury.
Inadequate Pressure Injury Prevention Leads to Resident Harm
During the January 28, 2025 inspection, state surveyors found that facility staff failed to implement proper pressure injury prevention measures for a resident with multiple risk factors. The resident, who had been admitted with chronic obstructive pulmonary disease, muscle weakness, adult failure to thrive, and other serious conditions, was identified as being at moderate to high risk for developing pressure ulcers.
Despite having a care plan that specifically addressed pressure ulcer prevention, staff did not follow the established protocols. The resident's care plan called for frequent repositioning, heel protection, and careful monitoring - interventions that could have prevented the injury that ultimately developed.
During the inspection, surveyors observed the resident in bed with inadequate positioning. The resident's left leg and heel were resting directly on the bed surface rather than being properly elevated on pillows as required by the care plan. Upon examination, nursing staff identified a red area on the resident's left lateral heel that showed signs of early pressure injury development.
Critical Assessment Errors Compromised Patient Safety
The inspection revealed significant problems with how staff assessed the resident's risk level for pressure ulcer development. Facility staff were using the Braden Scale, a standardized tool that evaluates factors like sensory perception, moisture exposure, and mobility to determine pressure ulcer risk.
However, the assessment contained multiple inaccuracies that understated the resident's actual risk level. Staff incorrectly rated the resident's sensory perception as having "no impairment" when the resident actually had limited ability to communicate discomfort. They also underestimated the resident's moisture exposure and mobility limitations.
These assessment errors had serious consequences. When properly scored using accurate information, the resident should have been classified as high risk rather than moderate risk for pressure ulcer development. This misclassification meant the resident did not receive the intensive prevention measures appropriate for their actual risk level.
The treatment nurse confirmed during the inspection that the observed redness was "blanchable," meaning it turned white when pressed, indicating early-stage tissue damage. However, facility documentation inconsistently described the area as "non-blanchable," suggesting possible deep tissue injury - a more serious condition where damage occurs from the bone outward.
Medical Significance of Pressure Injury Prevention
Pressure injuries develop when sustained pressure restricts blood flow to tissues, typically over bony prominences like heels, tailbones, and hips. In vulnerable populations like nursing home residents with limited mobility, these injuries can progress rapidly from minor skin redness to deep, painful wounds that may become infected or require surgical intervention.
For residents with conditions like COPD, heart failure, and muscle weakness - as seen in this case - pressure injury prevention becomes even more critical. These medical conditions can impair circulation and healing, making even minor pressure injuries more likely to progress to serious wounds.
The heel is a particularly vulnerable location because it naturally bears significant pressure when residents are positioned in bed. Proper heel protection involves "floating" the heels on pillows or specialized devices to eliminate all contact with the bed surface. This technique, specifically mentioned in the resident's care plan, was not being implemented consistently.
Systemic Issues in Care Plan Implementation
The facility's own policies emphasized the importance of identifying at-risk residents and implementing individualized interventions. Their March 2023 policy on pressure ulcer prevention specifically required staff to "evaluate resident-specific risk factors" and implement "appropriate individualized interventions."
The policy outlined a systematic approach: identify risks upon admission, regularly reassess those risks, and monitor the effectiveness of prevention interventions. However, the inspection findings suggest these policies were not being followed in practice.
The resident required assistance with repositioning and had been assessed as needing substantial help with basic activities like dressing, showering, and toileting. These functional limitations should have triggered more intensive monitoring and prevention protocols.
Additional Issues Identified
Beyond the primary pressure injury prevention failures, the inspection documented broader concerns about the facility's approach to resident assessment and care planning. The inconsistent documentation regarding the heel injury's severity raised questions about staff training and communication protocols.
The facility also showed deficiencies in following established nutritional interventions, as the resident had physician orders for between-meal nutritional supplements that were part of managing their failure to thrive condition.
State regulations require nursing homes to maintain comprehensive systems for preventing avoidable harm to residents, particularly those with multiple chronic conditions who depend on staff for basic care needs. When these systems fail, vulnerable residents face increased risks of developing painful, potentially life-threatening complications that could have been prevented through proper nursing care.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Rehabilitation Center On Pico from 2025-01-28 including all violations, facility responses, and corrective action plans.
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