A Red Heel Can Be the Start of a Pressure Injury. Check the Skin Before Discharge

Your parent has spent more time in bed than usual. A nurse mentions a red heel. Or you notice a dark area near the tailbone while helping with clothing.

Local option: New Plan Care gives families in the St. Louis area in-home help so a parent can stay home: companionship, help with bathing and dressing, meals, and overnight care. Call (314) 405-0887.

Do not try to name or stage it yourself. Ask the nurse to look at it now.

A pressure injury can begin when skin stays under pressure for too long. Heels, ankles, hips, elbows, the tailbone, and the back of the head are common places. Risk rises when a person cannot change position without help, spends most of the day in bed or a chair, has fragile skin, has reduced sensation, or has trouble keeping skin dry. MedlinePlus describes these risks and advises checking the skin every day. The National Institute on Aging also says that sitting or lying in one position for a long time can lead to pressure sores.

Day 0, still in the bed: decide whether this is your problem

Start with one direct question: “Can my parent move enough to take pressure off the same spots without another person helping?”

Do not answer from what your parent could do before admission. Watch what happens now. Can your parent lift each heel? Shift weight in the chair? Roll onto one side and then the other? Notice discomfort and respond to it? Call for help before sliding down in bed?

If the answer is no, partly, or only with repeated prompting, pressure protection belongs in the discharge plan.

Ask the nurse to inspect the skin with you. Include the heels, ankles, hips, buttocks, tailbone, elbows, shoulder blades, and back of the head. Ask what the staff sees, whether the area is intact or open, and whether it has been documented. CMS uses skin integrity and the presence of pressure injuries as specific assessment items across post-acute care settings. That is a reason to ask for precise words, not “skin looks a little irritated.”

Watch for a patch that stays red, looks purple or maroon, feels warmer or cooler than nearby skin, feels firm or unusually soft, is painful, or has become a blister or open area. Changes may look different on darker skin, so compare color, temperature, texture, and tenderness with the surrounding area. MedlinePlus identifies these as possible early signs and advises contacting the health care provider when a new sore or skin change appears.

Ask what caused the pressure. It may be the bed position, a chair, a shoe, a brace, oxygen tubing, a splint, or another device. Then ask what is keeping the pressure off that exact place now.

Before discharge: get a plan you can repeat

Ask the team to write down four things:

First, which areas need to be checked. “Check skin daily” is not enough. Name the locations.

Second, how your parent should be positioned in bed and in a chair. Ask how often the position should change and whether the schedule is different for bed and chair. General sources give example intervals, but your parent’s written plan should account for mobility, skin condition, equipment, comfort, and other medical limits. Do not create your own turning schedule from a general handout.

Third, what equipment or supports are required. Ask the staff to identify each item by function, such as floating the heels or reducing pressure while seated. Have them show you where it goes. A pillow placed in the wrong spot may not unload the area you are trying to protect.

Fourth, what change requires a call, which number to use, and how quickly to call. Include nights and weekends.

Federal hospital discharge planning rules require the hospital to evaluate likely needs after discharge and the availability and capability of caregivers. The evaluation must be discussed with the patient or the person acting for the patient under 42 CFR 482.43. Say plainly if you cannot turn your parent safely, inspect the skin, or provide the required help through the night. That information changes the plan.

Ask to practice one complete position change. Do it with the bed arranged as it will be at home as closely as possible. Let the staff watch your hands, your parent’s movement, and any sliding across the sheet. Mercy’s public pressure injury guide tells patients to reduce rubbing during repositioning by lifting instead of dragging. Family Caregiver Alliance also tells families to ask for bedside training in turning a person and preventing bedsores.

If an area is already open or covered with a dressing, ask who is responsible for the wound after discharge. Get the dressing instructions, supply list, first follow-up, and contact number in writing. Do not add creams, powders, antiseptics, or dressings that are not in the plan. BJC’s public wound care guidance tells patients to clean and dress a wound as directed and not put unapproved products into it.

Day 1, the car pulls in: check the places where pressure changes

The car seat, wheelchair, recliner, and home mattress do not support the body in the same way as the hospital bed.

When your parent reaches the first safe place to rest, look at the position before settling in. Are both heels resting against a firm surface? Is the tailbone taking most of the weight? Is your parent sliding down? Is a tube, brace, seam, or shoe pressing into the skin?

Use only the supports and positions the team approved. Do not place a ring or doughnut cushion under a sore area. MedlinePlus warns that ring-shaped cushions can reduce blood flow around the area.

Write down the first skin check. You need a simple baseline: location, color, whether the skin is intact, temperature compared with nearby skin, tenderness, and any drainage. A private photo may help only if your parent agrees and the clinical team wants images for comparison. A photo does not replace a call.

If home health was ordered, confirm the agency has the referral and knows there is a skin concern. Ask when the first visit will occur. Medicare says covered home health services can include skilled wound care and patient or caregiver education when eligibility requirements are met. An order is not the same as a confirmed visit.

Day 2 to Day 3, the first full days: test whether the plan works all day

Now count the work.

Who checks the skin in the morning? Who helps with each position change? Who cleans and dries the skin after urine or stool? Who handles the evening and overnight plan? Write names beside the tasks.

If a person is sitting or lying in the same position longer than the written plan allows because no helper is available, you have found the gap. If repositioning requires more strength than one person has, you have found another gap. Tell the ordering clinician or home health nurse. Do not wait for the skin to open.

Keep moisture separate from pressure in your notes. Urine, stool, sweat, and drainage can irritate skin, while pressure can injure tissue over a bony area. Both can be present. Ask the nurse what cleaning and moisture barrier plan applies. The National Institute on Aging advises caregivers to dry skin folds, check for rashes, and use a protective ointment for incontinence when appropriate.

Also watch whether your parent is eating and drinking according to the discharge plan. Do not invent a special diet or force fluids when there are restrictions. Ask the clinician if poor intake is affecting the skin plan.

Day 3 to Day 7, the week: compare the skin with the baseline

Use the same locations and the same words each day. Is the area smaller, unchanged, or larger? Is the color lighter or darker? Is the skin still intact? Is there new warmth, swelling, pain, drainage, odor, blistering, or an open spot?

Call the listed clinician when a new area appears or an existing area changes. MedlinePlus says to contact the provider promptly for a blister, open sore, foul odor, pus, redness and tenderness around the sore, warmth, swelling, or fever. Follow the discharge instructions for urgent symptoms and use emergency services when the instructions tell you to.

If home health care is not arriving as arranged, call the agency and the hospital discharge contact. Record whom you spoke with and what was promised. Missouri law provides a complaint process for licensed home health agencies under section 197.435, and the Missouri Department of Health and Senior Services regulates and investigates complaints involving covered home care providers. Start with the agency’s clinical supervisor when a visit or care problem can still be corrected quickly.

If the plan requires help you still do not have, use Local Help After a Discharge to find the appropriate St. Louis contact route. Keep the hospital instructions, skin notes, supply list, agency name, and phone numbers together.

The question for the end of the week is simple: can your parent reliably get pressure off vulnerable skin, or is another person still doing that work? If another person is required, keep that task assigned. A healing area does not make the mobility problem disappear.

Source basis: Medicare, Home Health Services; CMS, Discharge Planning Checklist and CARE skin integrity materials; 42 CFR 482.43; Missouri Revised Statutes section 197.435; Missouri Department of Health and Senior Services, Home Care; National Institute on Aging, Skin Care and Aging; MedlinePlus, Pressure Sores and Skin Care and Incontinence; Family Caregiver Alliance, Hospital Discharge Planning and Pressure Ulcer resources; Mercy, patient guidance on preventing pressure injuries; and BJC, wound care guidance. The desk’s source method is explained at Sources.