Failure to Obtain Physician's Order for Diabetic Foot Ulcer Treatment
Summary
The facility failed to obtain a physician's order from the attending physician as recommended by the consulting podiatrist for a resident with a diabetic foot ulcer. The resident, who had severe cognitive impairment and multiple medical conditions including Type 2 diabetes mellitus and an acquired absence of the left great toe, was admitted to the facility with no initial skin breakdown. However, an incident report later indicated the presence of a small ulcer on the left great toe, which was subsequently treated by a podiatrist with recommendations for specific topical treatments such as Bacitracin and Mupirocin. These recommendations were not followed up with physician orders in the resident's medical records, leading to a lack of proper documentation and treatment administration as per the podiatrist's advice. The review of the resident's medical records, including the Medication Administration Records (MARs) and Treatment Administration Records (TARs), revealed that there were no physician orders for the recommended treatments from the podiatrist. The facility's handwritten nursing skin assessments and physician progress notes also did not reflect any orders for Bacitracin or Mupirocin. Despite multiple podiatry consultations and recommendations, the necessary physician orders were not obtained, and the treatments were not documented in the resident's records. Interviews with the facility staff, including the LPN Unit Manager and the Director of Nursing, confirmed that the attending physician from 2022 was no longer working at the facility and that the podiatrist who initially treated the resident was also no longer available. The Director of Nursing acknowledged that when a consulting doctor makes a recommendation, the attending physician needs to write an order. The facility's policy on medication administration emphasized that medications should be administered as prescribed, which was not adhered to in this case.
Penalty
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A facility failed to ensure appropriate foot care for three residents by not trimming long, thick toenails and not arranging timely podiatry services. One resident with dementia and weakness, one resident with diabetes and multiple ADL needs, and one resident on hospice with PVD and other serious diagnoses all had documented long or thick toenails, with observations showing overgrown nails and buildup; staff interviews confirmed the residents had not been seen by podiatry as expected and that the nail care concerns had not been addressed in a timely manner.
Failure to provide ordered podiatry care: A resident with DM, hemiplegia, and limited ROM had long, cracked toenails with redness around the nail beds and reported foot pain. The resident said she had asked the SW for a podiatry visit but had not been seen. The DON observed the feet and agreed the toenails needed podiatry care, while records showed a referral was sent but no documentation of a podiatry eval was available despite a physician order for podiatry services.
Failure to provide proper foot care occurred when a resident with DM, COPD, CHF, and moderate cognitive impairment had overgrown great toenails observed on both feet. An LPN confirmed the nails needed trimming, while the SSD said the family had declined podiatry services and the resident was not on the podiatry list. A lead CNA and the DON stated nursing staff were responsible for routine foot care and skin checks, and the facility policy required daily nail care and regular trimming.
Failure to Provide Foot Care and Toenail Trimming: A resident who was dependent on staff for all ADLs and had severely impaired cognition, CP, epilepsy, respiratory failure, and dysphagia had very long toenails on admission. The care plan did not address foot or toenail care, the record lacked documentation of podiatry involvement or foot care, and staff interviews showed inconsistent understanding of who was responsible for trimming nails.
Failure to Provide Ordered Foot Care and Skin Monitoring: A resident with DM, diabetic polyneuropathy, and moderate pressure-injury risk developed a worsening left lateral foot ulcer and a new right great toe ulcer after staff did not document daily skin checks, did not provide daily foot washing, did not implement the podiatry and wound care recommendations, and did not keep the heels fully offloaded while in bed.
Failure to Provide Appropriate Foot Care and Wound Monitoring: Two residents with diabetes and poor circulation/sensation did not receive consistent foot monitoring and wound follow-up. One resident developed a blister between the toes that progressed to necrotic diabetic ulcers and gangrene, with no documented toe treatment orders and delayed podiatry follow-up before hospitalization and toe/partial foot amputation. Another resident developed a heel blister that was not evaluated at the weekly wound visit, was not consistently offloaded in bed, and was later opened when a lidocaine patch was removed from the heel.
Failure to Provide Timely Toenail Care and Podiatry Referral
Penalty
Summary
The facility failed to ensure appropriate foot care for three residents by not ensuring toenails were trimmed and by not arranging podiatry services in a timely manner. Resident #34, who had vascular dementia, heart disease, and muscle weakness, was dependent on staff for ADL care and was cognitively intact on assessment. Review of weekly nursing assessments from January through July 2026 showed no notation that her toenails were long and thick or needed trimming, and there were no podiatry consultation reports or EMR notes showing she had been referred to or seen by podiatry since admission. Resident #34’s responsible person reported that the resident’s toenails had been long and thick for months, that the left great toenail had become tender and possibly ingrown, and that she had repeatedly been told the resident would be added to the podiatry schedule but had still not been seen. On observation, Resident #34 had thick, long toenails, with both great toenails thick and raised away from the skin and the left great toenail with slight redness on the side believed to be ingrown. Staff interviews confirmed that the toenails were too long and thick for routine in-house care and that podiatry should have been arranged. Resident #65, who had acidosis, chronic bronchitis, asthma, and diabetes mellitus, was dependent for several ADLs and had no rejection of care documented on the MDS. Her care plan directed aides to check nail length and trim and clean nails on bath day and as necessary, but weekly nursing assessments from May through July 2026 did not note long or thick toenails. During observation, her right great toenail extended about three-quarters of an inch beyond the toe, and staff later observed both feet had very long, thick toenails with other nails curling over the toes. Interviews showed the resident refused fingernail care but did not object to toenail trimming, and staff stated she needed podiatry; however, she had not yet been seen. Resident #44, who had MRSA infection, peripheral vascular disease, multiple skin cancers, hypertension, gait and coordination deficits, colon cancer, and hospice care, also had care plan instructions for nail length checks and trimming/cleaning as needed. A podiatry referral identified thickened, dystrophic, or painful toenails requiring evaluation, but the resident was never added to the podiatry clinic list and was not scheduled for the next clinic. Observations showed all 10 toenails were elongated and thick with red-brown buildup beneath and around the nails and cuticles. Staff interviews confirmed the toenails should have been cleaned and trimmed and that podiatry care should have been arranged sooner, while the resident was agreeable to podiatry services.
Failure to Provide Ordered Podiatry Care
Penalty
Summary
Provide appropriate foot care. The facility failed to ensure that one of three sampled residents, Resident 1, received podiatry treatment services as ordered by the physician. Resident 1’s annual MDS dated 5/29/26 indicated she was admitted to the facility on [DATE], had a BIMS score of 15, and had functional limitation in range of motion to the upper and both lower extremities. Her diagnoses included hemiplegia and diabetes mellitus. During a 7/23/26 observation and interview, Resident 1 was awake and lying in bed with long, cracked toenails and reddish discoloration around the toenail bed. She stated she was diabetic and had asked the social worker to have her seen by a podiatrist for concerns about her feet and toenails, but she had not yet been seen. Later that day, the DON observed Resident 1’s feet and stated her toenails needed podiatry care. Record review showed a 7/2/26 social services note indicating a referral was sent to podiatry for evaluation and treatment, but the SSD could not provide documentation that Resident 1 received podiatry evaluation. A physician order dated 9/24/25 directed that Resident 1 receive podiatry care, and the facility’s P&P stated podiatry services would be provided timely and as clinically indicated.
Failure to Provide Proper Foot Care
Penalty
Summary
Proper foot care was not provided or arranged for one resident with diabetes, COPD, CHF, and moderate cognitive impairment who required staff assistance with personal hygiene. Medical record review showed the resident was admitted on 03/21/26, and observation on 07/23/26 at 8:13 A.M. revealed both great toenails were overgrown. An LPN confirmed at 8:14 A.M. that both feet had overgrown toenails on the great toes and that the nails needed to be trimmed. Interviews and record review showed the resident was not on the facility’s ancillary services list for podiatry. The SSD stated the family had opted not to enroll the resident to be seen by the facility podiatrist during the admission care conference. A lead CNA stated that if a resident was not on the podiatry list, nursing staff should take care of the resident’s feet and trim toenails as needed. The DON confirmed nursing staff were ultimately responsible for foot care and regular skin checks, including observing residents’ feet, and that nursing should address issues discovered. The facility policy stated nail care should occur daily with cleaning and regular trimming, and that CNAs were not to trim nails of diabetic residents or residents with circulatory problems.
Failure to Provide Foot Care and Toenail Trimming
Penalty
Summary
The facility failed to provide foot care to a resident who was dependent on staff for all activities of daily living and had severely impaired cognition, spastic quadriplegic cerebral palsy, epilepsy, acute and chronic respiratory failure with hypoxia, seborrheic dermatitis, and dysphagia. The resident’s care plan directed staff to provide total assistance with dressing, personal hygiene, and oral care, and to inspect skin every shift, but it did not include direction for toenails or foot care. The resident’s admission paperwork from the acute hospital documented very long toenails, and the admission photograph showed a thick right big toenail and other toenails extending considerably past the tops of the toes. Records reviewed did not show that the resident was seen by podiatry during the month reviewed, and progress notes from the period reviewed lacked documentation addressing the resident’s feet or toenails. Bath sheets documented no concerns, but there was no documented foot care intervention. The resident’s representative stated he had asked facility staff and administration about the resident being seen by a podiatrist for his toenails. Staff interviews showed inconsistent understanding of who was responsible for nail care, with a CNA stating she would only notify the nurse, a nurse stating podiatry or administrative nursing handled nail trimming, and an administrative nurse stating she would trim nails unless podiatry needed to attend to them.
Failure to Provide Ordered Foot Care and Skin Monitoring
Penalty
Summary
The facility failed to provide proper foot care and skin monitoring for a resident with type 2 DM, diabetic polyneuropathy, vascular dementia, CKD, protein-calorie malnutrition, and impaired mobility. The resident’s Braden score was 13, indicating moderate risk for pressure injury, and the care plan for skin breakdown called for skin checks during daily care and notification of the physician for abnormal findings. The resident’s admission record and MDS showed the resident was at risk for skin impairment and required assistance with bed mobility. On 6/26/2026, a Podiatry NP evaluated the resident after complaints of painful thick toenails and numbness and tingling in both feet and identified a diabetic ulcer on the left lateral foot measuring 0.9 cm x 0.9 cm x 0.1 cm. The NP recommended aggressive pressure offloading with heel protectors and pillows, daily inspection for cracks, blisters, and sores, daily washing of the feet with warm water, drying between the toes, lotion use, and supportive footwear. The resident’s treatment record showed an order to cleanse the left foot ulcer and apply xeroform with a dry dressing daily. The resident later developed worsening foot wounds. On 7/9/2026, the WCC documented the left lateral foot ulcer had increased to 1.8 cm x 1.8 cm x UTD with about 80% necrotic eschar and 20% slough, and a new diabetic ulcer was found on the right great toe measuring 0.8 cm x 0.8 cm x 0.2 cm with necrotic tissue and tenderness to palpation. During observation on 7/15/2026, the resident was wearing socks with both heels in contact with the bed surface, and CNA 1 stated the resident needed heel elevation but the pillow under the lower legs still allowed the heels to touch the bed. CNA 1 also stated she washed the resident’s feet only on shower days, not daily. TN 1 stated there was no documented evidence that skin observations were done during the reviewed period, that the frequency had been set to as necessary rather than daily, and that the additional recommendations from the Podiatry NP and WCC were not implemented. The DON also stated the diabetic foot care measures from the facility policy and the specialists’ recommendations should have been incorporated into the resident’s care plan.
Failure to Provide Appropriate Foot Care and Wound Monitoring
Penalty
Summary
The facility failed to provide appropriate foot care for two residents with diabetes and impaired circulation/sensation. One resident had a left below-the-knee amputation, diabetic neuropathy, and a care plan directing staff to inspect the feet daily, keep socks clean and nonconstricting, use non-skid footwear, and refer to podiatry for foot care and toenail trimming. A physician documented a new blister between the toes with drainage and no pain due to absent sensation, and planned a podiatry referral for diabetic foot disease. Weekly skin assessments later documented redness and tenderness, then a popped blister, dry scabs, and later dry eschar and necrotic diabetic ulcers on the right toes, but the record showed no corresponding treatment orders for the toes and no nurse progress notes documenting the wound changes. The resident’s foot condition worsened without timely documented follow-up. The physician and NP notes showed an active podiatry order, but the resident did not see the podiatrist, and no wound care specialist documentation was found in the record. The facility investigation timeline identified that the blister was first noted, then later described as sloughed, scabbed, and worsening, before the resident was sent to the hospital for abnormal vital signs and decline in status. Hospital records documented wet and dry gangrene of two toes, and the resident later required surgery for toe amputation and then partial foot amputation. A second resident with diabetes, poor circulation, and poor sensation developed a blister on the right heel that was identified in the facility incident report log and investigation packet. The resident was ordered topical treatment and heel offloading, but during observation the resident’s heels were resting on the mattress without pillows, and the resident reported heel pain. Staff stated the wound care provider did not evaluate the blister at the weekly visit when other wounds were assessed, and the blister was first evaluated later, when a lidocaine patch was removed and the blister opened. The DON stated the lidocaine patch was not indicated for a heel blister and should not have been applied over it.
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