Failure to Provide Timely Foot Care Leads to Resident's Toe Necrosis
Summary
The facility failed to provide appropriate foot care for a resident, leading to a serious health issue. The resident, who had severe cognitive impairment and multiple medical conditions including type 2 diabetes mellitus, experienced pain in the right first and second toes, which was documented by staff on January 23, 2024. Despite this documentation, the issue was not addressed by a physician until February 19, 2024, when the toes were found to be red and sore, with the second toe showing signs of necrosis. This delay in addressing the resident's foot condition resulted in the need for urgent medical intervention, including a podiatry referral and vascular studies. The resident's care plan included interventions for diabetes management and skin integrity, but these were not effectively implemented to prevent the complication. The resident's medical records indicated that a podiatry referral was pending for several weeks, and the necessary care was not provided in a timely manner. The facility's staff, including the Physician Assistant, failed to act on the initial reports of toe pain, and the resident's condition worsened significantly over the following weeks. Interviews with facility staff revealed a lack of clarity and responsibility regarding the process for making podiatry referrals. The Director of Nursing and Resident Advocate both indicated that the responsibility for referrals had shifted, and there was confusion about who was accountable for ensuring the resident received timely care. This lack of coordination and communication contributed to the delay in addressing the resident's foot condition, ultimately leading to the need for surgical intervention.
Penalty
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A diabetic resident with impaired cognition and vascular dementia, who required assistance with mobility and toileting, did not receive routine foot and nail care despite a care plan directing staff to monitor skin and provide ordered treatments. Physician orders for the month lacked any nail care directives, and there was no documentation that nail care had been performed. Although podiatry services were eventually authorized by the resident’s durable power of attorney, observations later showed the resident complaining of foot pain, with overgrown, curling toenails causing reddened indentations on adjacent toes and white tissue noted between and along the toes.
A resident with multiple comorbidities did not receive wound care as ordered for an arterial ulcer on the right foot, and comprehensive assessment of a surgical wound following amputation was not completed. Documentation was lacking for both the administration of wound care and the assessment of the surgical site, as confirmed by facility leadership.
A resident with cognitive deficits and a history of combative behavior was observed with extremely long, thick, and curled toenails after repeatedly refusing nail care from staff and a podiatrist. Staff and medical record reviews revealed a lack of documentation regarding family notification and care conference discussions about the refusals, despite facility policy requiring proper foot care and communication.
A resident with multiple medical conditions was not provided timely podiatry care due to a delay in obtaining consent for auxiliary services and a lack of awareness among staff. The resident was observed with long, thickened, yellow toenails, and staff interviews confirmed there was no specific policy for podiatry services, resulting in the resident missing needed foot care.
A resident with multiple comorbidities did not receive physician-ordered Plavix and Aspirin following a vascular procedure, and the facility failed to arrange transportation for follow-up appointments due to a lack of a non-emergent ambulance contract. As a result, the resident's arterial wounds worsened, leading to osteomyelitis and the need for emergent hospital care.
A resident with diabetes, hemiplegia, and severe cognitive impairment was not properly monitored for a diabetic foot ulcer. Required interventions, such as applying protective boots and floating legs, were not consistently implemented, and weekly wound assessments lacked necessary measurements and descriptions. Staff interviews and observations confirmed lapses in following the care plan and facility policy for wound care documentation and intervention.
Failure to Provide Routine Foot and Nail Care for Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure routine foot care for a diabetic resident with impaired cognition and vascular dementia. The resident was admitted with diagnoses including acute and chronic heart failure, type 2 diabetes, and vascular dementia, and required setup assistance for eating and moderate assistance for toileting, bed mobility, and transfers. The care plan identified diabetes mellitus with insulin dependence and included interventions such as blood glucose monitoring, diet and medications as ordered, and checking the body for skin breaks. However, review of the physician’s orders for the relevant month showed no orders related to nail care, and the facility was unable to locate any documentation that nail care had been provided. The resident’s quarterly MDS showed impaired cognition without behaviors or rejection of care. The resident initially did not authorize podiatry services per a consent form, but a later podiatry services authorization form showed that the durable power of attorney consented to podiatry services. A weekly nursing skin and body review documented a head-to-toe assessment with no new skin areas noted shortly before the deficiency was identified. Subsequent observations revealed the resident attempting to self-propel in a wheelchair, bumping her foot and stating that it hurt. A focused observation of the left foot showed overgrown nails on the third and fourth toes extending past the end of the toes and curling toward adjacent toes, causing reddened indentations where they touched. The great toe had white-colored tissue at the end of the toe, between the great and second toes, and along the side of the second toe, and the resident complained of pain when questioned by staff. These findings demonstrated that routine foot and nail care had not been provided as needed for this diabetic resident.
Failure to Provide Ordered Wound Care and Comprehensive Wound Assessment
Penalty
Summary
The facility failed to provide wound care as ordered for an arterial ulcer on a resident's right foot and did not complete a comprehensive wound assessment for a surgical wound on the same resident. Medical record review showed that the resident, who had diagnoses including COPD, diabetes mellitus, and peripheral vascular disease, was admitted with an arterial ulcer on the right foot second digit. Orders were in place for daily and as-needed application of barrier spray/wipes, but documentation on the Treatment Administration Record did not support that these treatments were completed as ordered. The wound physician's note and physician orders specified the required care, but the order was incorrectly entered into the electronic health record as 'as needed' only, rather than 'daily and as needed.' The resident later complained of the toe being dead, was hospitalized, and subsequently underwent amputation procedures. Further review of the medical record after the resident's return from the hospital revealed incomplete documentation regarding the surgical wound. Admission and weekly skin assessments noted the presence of amputated toes but did not include measurements or descriptions of the surgical site. Interviews with the Administrator and DON confirmed the lack of documentation for both the wound care provided and the assessment of the surgical wound, which was not in accordance with the facility's wound care policy that requires detailed recording of wound care and assessments.
Failure to Provide Adequate Foot Care Due to Incomplete Documentation and Communication
Penalty
Summary
The facility failed to provide adequate foot care for a resident with a history of traumatic brain injury, aphasia, and cognitive deficits. The resident was noted to have self-care deficits and was frequently resistive or combative during attempts at nail care, both by staff and an outside podiatrist. Despite repeated refusals, there was no documentation that the resident's family was notified of the ongoing issue, nor was there evidence that refusals were discussed during care conferences. Observations revealed the resident's toenails were extremely long, thick, and curled, and staff interviews confirmed awareness of the resident's refusal and the lack of a clear plan to address the situation. Medical record reviews showed multiple missed opportunities to document and communicate the resident's refusals and the resulting condition of her toenails. The facility's policy required ensuring proper foot care, but interventions such as reapproaching the resident or educating the family were not consistently documented or implemented. The podiatrist suggested the possibility of sedation to facilitate nail care, indicating the chronic nature of the problem, but there was no evidence that this recommendation had been acted upon or communicated to the family.
Failure to Provide Timely Podiatry Services
Penalty
Summary
A deficiency was identified when a resident did not receive timely podiatry services. The resident, who had diagnoses including muscle weakness, vascular dementia, and epilepsy, was observed to have long, thickened, yellow toenails on both great toes. Review of the medical record showed that although the resident was readmitted to the facility, a consent for auxiliary services, including podiatry, was not obtained until several weeks later. During this period, the resident did not receive podiatry care, and the need for such services was not recognized until a care conference was held. Interviews with facility staff confirmed that there was no specific policy in place for podiatry services, and the social services designee was unaware of the resident's need for podiatry until the care conference. The podiatrist's last visit to the facility occurred prior to the consent being obtained, and the next scheduled visit was after the deficiency was identified. The lack of timely consent and absence of a clear process for arranging podiatry services led to the resident not receiving necessary foot care.
Failure to Provide Post-Vascular Procedure Care and Follow-Up
Penalty
Summary
The facility failed to provide adequate and necessary comprehensive, resident-centered care to a resident following a vascular procedure for arterial stenosis. After undergoing an angiogram and stent placement, the resident was discharged with physician orders to receive Plavix 75 mg daily and Aspirin 81 mg daily to maintain stent patency and prevent complications. However, the medical record revealed that the resident had not received Aspirin since the previous year, and Plavix was never administered after being ordered. There was also no care plan addressing the resident's post-procedure care, follow-up appointments, or transportation needs. The resident, who had multiple comorbidities including diabetes, peripheral vascular disease, dementia, and chronic kidney disease, required assistance with activities of daily living and had a history of arterial/ischemic ulcers. Despite the physician's orders and the resident's high risk for complications, the facility failed to arrange transportation for follow-up appointments with the vascular surgeon. The lack of a contract with a non-emergent ambulance service resulted in multiple missed appointments, and the facility did not reschedule or ensure the resident was evaluated by the vascular surgeon after the procedure. As a result of these failures, the resident's arterial wounds deteriorated, leading to the development of osteomyelitis in the left foot. The wounds showed signs of infection, including purulent drainage, necrotic tissue, and exposed bone. The resident ultimately required emergent transport to the hospital, where intravenous antibiotics were initiated for the treatment of osteomyelitis. Interviews with facility staff confirmed the missed medication administration and transportation issues, as well as a lack of awareness regarding the resident's missed follow-up care.
Failure to Monitor and Implement Wound Care Interventions
Penalty
Summary
A resident with multiple complex medical conditions, including hemiplegia, diabetes mellitus with a foot ulcer, and severe cognitive impairment, was not properly monitored or treated for a diabetic foot ulcer. The care plan required the application of protective boots, floating of legs with pillows, and ongoing monitoring and documentation of the wound's size, depth, margins, and healing progress. However, medical record review showed that weekly wound assessments were incomplete, often missing measurements and detailed descriptions of the wound bed. Additionally, hospice notes provided to the facility lacked detailed weekly wound documentation, and the DON confirmed she had not reviewed these reports, which misidentified the wound as a stage two pressure ulcer. Observation revealed the resident was found in bed without the required protective boots, and their heels and legs were directly on the mattress, contrary to care plan interventions. Staff interviews confirmed inconsistent understanding and implementation of the boot application schedule. Facility policy required comprehensive wound documentation with each dressing change or at least weekly, but this was not followed, resulting in a failure to monitor the resident's wound and implement necessary interventions as outlined in the care plan and facility policy.
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