Failure to Provide Diabetic Shoes Leads to Amputation
Summary
The facility failed to ensure a resident with a history of bilateral foot diabetic ulcers received diabetic shoes as ordered by the physician. The order for diabetic shoes was placed on 7/10/24, but the facility did not follow up with the shoe vendor to ensure the shoes were ordered and delivered. This oversight continued throughout July, and by 8/30/24, the resident developed a foot ulcer, indicating a lack of preventative foot care measures. The resident, who had a history of Type 2 diabetes with foot ulcers and neuropathy, expressed a desire for diabetic shoes on 8/26/24. Despite this, the facility did not document any communication or follow-up with the shoe vendor between 7/10/24 and 8/30/24. The resident's condition worsened, leading to a wound on the left heel, which eventually required debridement and resulted in a left foot amputation on 10/26/24 and a below-the-knee amputation on 10/31/24. Interviews with facility staff and the shoe vendor revealed that the vendor requested additional paperwork to fulfill the shoe order, but the facility continued to send the same paperwork without addressing the vendor's request. The Director of Nursing stated that follow-up should occur within 24-48 hours, yet there was no evidence of such follow-up. The lack of timely action and communication contributed to the resident's deteriorating condition and subsequent amputations.
Removal Plan
- The DON and designee(s) conducted a full-house audit on diabetic residents to determine at-risk diabetics and ensure proper preventative foot care.
- An audit was conducted to ensure all treatments, supplies, and equipment were readily available for order by the physician and were being followed to ensure residents received the proper preventative foot care.
- DON or designee(s) reviewed the medical records of diabetic residents to ensure that weekly skin assessments were completed and treatment recommendations/orders were in place.
- The DON or designee conducted a care plan audit to ensure that treatment recommendations/orders were included in the care plan and that they were being followed.
- All facility policies and procedures related to podiatry services, skin integrity foot care, and physician orders reviewed and revised as needed.
- Education provided to regional Clinical Manager at Curana to ensure that all practitioners that come to Pine Acres will be collaborating with the IDT team to ensure referrals are made timely and appropriately.
- An audit of orders, interventions, and devices regarding foot care and foot services was conducted by the Nursing Supervisor(s) to ensure proper use.
- The DON/Corporate Nurse/Consultant educated all licensed nurses on facility policies and procedures related to diabetes, foot care, and appropriate wound treatment measures.
- The DON/Corporate Nurse/Consultant educated all licensed nurses on appropriate documentation, which included transcription and entering treatment orders on the physician's order sheet in the EHR and the resident's TAR.
- DON/Corporate Nurse/Consultant educated all nurse aides on preventative diabetic foot care.
- DON/Corporate Nurse/Consultant conducted daily treatment record and nursing documentation audits to ensure accurate and complete documentation of diabetic foot care and preventative measures.
- For residents returning from the hospital, treatment recommendations/orders and wound care appointments will be transcribed and overseen by the DON and Corporate Nurse.
- DON/Corporate Nurse/Consultant Monitoring will continue to monitor/audit the following: Observation of treatments for diabetic foot care prevention and orders, Weekly physician orders, Weekly diabetic skin treatment orders related to diabetics, Treatment recommendations and orders are being added and processed into the EHR and TAR.
- A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue.
Penalty
Resources
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The facility failed to ensure three diabetic residents received scheduled podiatry foot care to maintain proper toenail length, despite care plans directing referral to a podiatrist or foot care nurse and a contracted podiatry group visiting the facility. All three residents were on the podiatry list but were not seen during the most recent visit, and their last documented podiatry care had occurred several months earlier. One resident, cognitively intact and dependent for footwear, reported needing help with toenail cutting and had toenails extending beyond the toe with some curving toward the skin. Another cognitively intact resident who required substantial assistance with footwear stated he had not seen the podiatrist in a long time. A third resident with moderate cognitive impairment, who ambulated with a walker, reported asking staff about nail care, said her toenails were last cut the prior year, and described pain with wearing shoes and embarrassment; her toenails were visibly long. Staff interviews confirmed that the podiatry company did not see all residents on the last visit, could not return for several weeks, and that only the podiatrist trims toenails for residents with diabetes, consistent with facility policy. Leadership acknowledged that some residents did not receive foot care and that this placed them at risk for injury or infection and that long toenails can cause pain and be a fall hazard.
A resident with atrial fibrillation and heart failure, cognitively intact and needing assistance with ADLs, had long, jagged toenails and brown discoloration of the right great toenail that were not addressed by staff. Nursing assessments and the EMR contained no documentation of toenail issues, offers of toenail care, podiatry referrals, or refusals, even though a NA and a nurse both noticed the long, discolored nails and did not report, document, or act on these findings. The resident stated he had repeatedly requested toenail trimming, had not refused such care, and believed a podiatry visit had been promised but never arranged. Review of podiatry schedules showed the resident was not listed, and there were no podiatry consults or visit notes, while leadership acknowledged awareness of the toenail problem without corresponding documentation of care or refusals.
A resident with PVD, neuropathy, onychomycosis, dermatophytosis, left foot drop, and moderate protein calorie malnutrition received podiatry care with toenail debridement and a plan for follow-up in 6–8 weeks, but the care plan did not include foot or nail problems, and no subsequent podiatry treatment or refusals were documented over several months. Podiatry service lists repeatedly showed the resident was due for follow-up for tinea unguium, with visits rescheduled without documented reasons and one listed refusal not supported by nursing notes. The resident’s conservator later observed severely overgrown, curling toenails and reported not being informed of podiatry issues or refusals. The Administrator, DON, and APRN each reported they were not made aware of the podiatry findings or follow-up needs, and there was no designated nurse or process to ensure podiatry recommendations and visit outcomes were communicated to nursing staff or incorporated into ongoing care.
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 DM, hemiplegia, and hemiparesis, dependent on staff for ADLs but cognitively intact, had a physician order for a podiatry consult and treatment that was placed on hold during a hospital stay and not reactivated on return. Nursing staff were aware of the resident’s long, thickened toenails but did not complete a change of condition report or notify the physician, citing that staff generally would not trim toenails for a diabetic resident at high risk for infection. The resident reported only concern about the pending podiatry appointment, and observation confirmed long, thickened toenails on both feet, while facility policies required physician notification for significant changes and resident participation in care planning.
A resident with dementia, Parkinson’s disease, DM, and arthritis, who required extensive assistance with ADLs and was at risk for pressure ulcers, did not receive appropriate foot care or podiatry services. The care plan addressed only nutritional issues, and weekly nursing assessments did not document the resident’s increasingly long, thick toenails. The resident was never placed on the podiatry schedule and had not been seen by a podiatrist since admission. During observations, the resident’s toenails were found to be thick, long, jagged, with discoloration of the great toenail, and both the resident and family reported the resident could not care for her own feet. A NA stated she had noticed the long toenails but did not remember reporting it, while the wound nurse and ADON acknowledged the resident had not been referred for podiatry despite her DM.
Failure to Provide Timely Podiatry Foot Care for Diabetic Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide podiatry foot care and treatment in accordance with professional standards of practice for three residents with diabetes who were care planned to receive podiatry services. All three residents had care plans indicating diabetes mellitus with an intervention to refer to a podiatrist or foot care nurse to monitor and document foot care needs and to cut long nails. A local podiatry group was scheduled to provide services on 3/4/26, and all three residents were listed to be seen, but they did not receive foot care during that visit. Record review showed that the last podiatry service date for each of these residents was 10/28/2025, despite their insurance allowing 4–6 podiatry visits per year. Resident #1 was an 82-year-old female with unspecified dementia, type 2 diabetes mellitus, and a need for assistance with personal care, who was dependent on staff for putting on and taking off footwear and had no cognitive impairment per a BIMS score of 15. During observation and interview, she reported needing help cutting her toenails, stated she could not do it herself, and that nurses did not cut her nails because she had diabetes and the podiatrist had to do it. She reported her last toenail trimming was about five months prior. Her toenails were observed to extend up to 1/4 inch beyond the flesh of the toes, with some nails curving toward the skin. Resident #2 was a male with spinal stenosis with neurogenic claudication, type 2 diabetes mellitus, and a need for assistance with personal care, who required substantial to maximum assistance with footwear and had a BIMS score of 15. He stated that a podiatrist usually cut his toenails but that he had not seen her in quite a while. Resident #3 was a female with unspecified dementia, type 2 diabetes mellitus, a need for assistance with personal care, and moderate cognitive impairment with a BIMS score of 7, who ambulated with a walker. She reported asking staff about getting her toenails cut and being told it would occur when the podiatrist came, stated her toenails were last cut the previous year, and reported pain with wearing shoes and embarrassment. Her toenails were observed to be 1/2 to 1 inch beyond the flesh of the toe. A family member reported that a hospital had noted her need for nail care and that the podiatrist had left before seeing her at the last visit. The SW confirmed the podiatry company could not see everyone on the March visit, could not return until late April, and that only the podiatrist provided toenail care for residents with diabetes, consistent with the facility’s nail care policy stating that nail care, especially trimming, is performed by a podiatrist in those with diabetes and peripheral vascular disease. The DON and ADON acknowledged that some residents did not receive foot care and that this put them at risk for injury or infections, and that long toenails can be a fall hazard and cause pain.
Failure to Provide Toenail and Podiatry Care for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate foot care and arrange podiatry services for a cognitively intact resident with atrial fibrillation and heart failure who required moderate assistance with ADLs and was dependent for bathing. On admission and in subsequent weekly nursing assessments from late January through mid-March, there was no documentation of issues with the resident’s toenails, despite observations on March 16 that both feet had long, jagged toenails and the right great toenail had brownish discoloration extending from the base toward the middle of the nail. The resident reported having asked several times for toenail trimming, stated he had never refused toenail care, and said he had been told he would see a podiatrist but believed no appointment had been made. The EMR contained no documentation that toenail or podiatry care was offered or refused, although it did show refusals of showers and UNNA boot care. Staff interviews confirmed awareness of the toenail condition but revealed no follow-through. A NA who frequently cared for the resident stated he had noticed the toenails were very long and needed trimming but did not recall reporting this to a nurse and had not asked the resident about toenail trimming. A nurse reported the resident had been admitted with long, discolored toenails, especially the right great toe, but acknowledged he did not document this, notify the provider, or attempt to trim the nails, and he had not informed social work of the need for podiatry. The podiatry clinic schedules for February and March did not list the resident, and there were no podiatry consult notes or visit documentation in the EMR since admission. The Social Work Director stated he was unaware of any podiatry needs for this resident until a nurse requested adding the resident to the podiatry list on the day of the interview. The DON stated she was aware of the toenail issue and believed the resident refused care frequently, including toenail care, but there was no documentation of such refusals in the EMR.
Failure to Ensure Ongoing Podiatry Care and Follow-Up for Foot and Nail Abnormalities
Penalty
Summary
The deficiency involves the facility’s failure to provide ongoing podiatry care and timely follow-up for a resident with documented foot and nail abnormalities. The resident had diagnoses including mild cognitive impairment, dysthymic disorder, left foot drop, moderate protein calorie malnutrition, PVD, neuropathy, onychomycosis, and dermatophytosis. A podiatry note documented on 9/22/25 described thick, yellow, brittle toenails with subungual debris and indicated that aseptic debridement of all ten toenails was performed, with a plan for follow-up in six to eight weeks. However, the resident’s care plan from 9/22/25 through 2/9/26 did not include podiatry abnormalities, nail disorders, infections, or foot and nail diagnoses to guide ongoing treatment and monitoring. From 9/22/25 to 2/9/26, the clinical record contained no further podiatry treatment notes or documentation of refusals of podiatry care for this resident. Nurse’s notes during this period did not address the condition of the resident’s feet or toenails or any refusals of podiatry services, and the TARs for September 2025 through February 2026 did not show any treatments or monitoring related to the resident’s feet or toenails. Podiatry Service Lists dated 11/10/25, 12/22/25, and 1/6/26 showed the resident was due for follow-up for tinea unguium, but each visit was rescheduled without a documented reason, and the resident was not seen. A Podiatry Service List dated 2/3/25 indicated the resident was due for follow-up and refused the visit, but there was no corresponding nursing documentation of this refusal in the nurse’s notes from 2/3/26 through 2/9/26. The resident’s conservator later reported being shocked by the condition of the resident’s toenails, describing them as so thick and long that they were curling, and stated that the facility had not notified them of podiatry issues or refusals of care. The Administrator acknowledged being unaware of the 9/22/25 podiatry note and was unsure how nursing staff became aware of podiatry recommendations, noting that podiatry notes were sent to Medical Records and communication with the podiatry group occurred by email. The DON stated that nursing staff should have followed up on the 9/22/25 podiatry visit for orders and recommendations, assessed and documented the toenail condition, and notified leadership to facilitate timely follow-up, but there was no designated nurse responsible for coordinating podiatry visits and no process to ensure specialty providers’ findings were communicated to nursing before leaving the facility. The DON also reported misinterpreting several Podiatry Service Lists as refusals and could not determine why the resident was not seen on those dates. The APRN reported she was never notified of the podiatry findings or the reported refusal and stated that nursing should have documented and notified her of the podiatry visit and ongoing issues so that monitoring and timely follow-up could have occurred.
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 Resume and Act on Podiatry Order for Diabetic Resident
Penalty
Summary
The facility failed to provide podiatry care for a resident with diabetes, hemiplegia, and hemiparesis, who was dependent on staff for ADLs but had intact cognition for daily decision making. The resident had a physician’s order for a podiatry consult and treatment as needed, originally dated 11/2/25. After the resident was hospitalized, all physician orders were placed on hold. When the resident returned from the hospital, staff resumed all orders except the podiatry consult, which remained on hold and was not active. The resident reported that a staff member had recently indicated they would make a podiatry appointment, but the resident had not received any update on the status of that appointment. Nursing staff were aware of the resident’s foot condition but did not act on it. An LVN stated they observed the resident’s long and thickened toenails on 11/20/25 when completing a Change of Condition report for heel redness, but they did not complete a change of condition report related to the toenails and did not notify the physician about this issue. The LVN also stated that, because the resident was diabetic and at high risk for infection, facility staff generally would not trim the resident’s toenails. On observation, the resident’s toenails on both feet were noted to be long and thickened. Facility policies on resident rights and change in condition required that residents be informed of and participate in their care and that physicians be notified of significant changes in condition, but these processes were not followed for the resident’s podiatry needs.
Failure to Provide Foot Care and Arrange Podiatry for Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate foot care and arrange podiatry services for a resident with dementia, Parkinson’s disease, and diabetes mellitus. On admission, the nursing assessment did not note any toenail issues, and the admission MDS documented moderately impaired cognition, need for assistance with mobility, toileting, transfers, bathing, and dressing, as well as diagnoses of Parkinson’s disease, dementia, DM, and arthritis, and risk for pressure ulcer development. The resident’s care plan, developed by the RD, addressed only potential nutritional problems and did not include any other care areas. Weekly nursing assessments over several months contained no notation that the resident’s toenails were long, thick, or needed trimming. Review of the podiatry clinic schedule and EMR showed the resident was not scheduled for, nor seen by, a podiatrist since admission. During observations, surveyors noted the resident had thick, long, jagged toenails on both feet, with a brownish discoloration at the base of the left great toenail extending toward the middle of the nail. The resident stated her toenails looked “nasty,” that she could not bend down to care for her feet, and that her daughter had trimmed her toenails before admission. The wound nurse acknowledged she did not notice the resident’s toenails and had not requested that she be added to the podiatry list. The ADON stated the resident should be seen by a podiatrist because she was diabetic and confirmed that, although responsible for adding residents to the podiatry schedule in the absence of a Social Worker, she had not referred this resident since admission. A NA who frequently provided showers reported noticing that the resident’s toenails were very long and needed trimming but could not recall if she reported this to a nurse. The resident’s family member confirmed the resident had been unable to care for her feet for a long time and that she previously kept the toenails trimmed due to the resident’s diabetes.
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