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
Below are regulatory guidelines relevant to this citation:
A resident with aphasia, HTN, hemiplegia/hemiparesis, and idiopathic peripheral neuropathy had two calloused areas on the bottom of the right foot noted on admission, but the record showed no follow-up skin assessments, no wound measurements, no physician notification, and no treatment started. During observation, the resident indicated pain in the foot, and the RN stated she had been waiting for the MD to see the resident; however, no padding was in place and the areas were not being protected.
Omitted Left Foot Treatment and Missed Podiatry Follow-Up: A resident returned from the hospital with discharge instructions for nursing treatment to a laceration on the left 5th toe and a podiatry follow-up for fractures of the 4th and 5th toes, but the facility did not enter the foot treatment orders or schedule the podiatry appointment. Staff were unsure about any left foot wound or treatment, and surveyors observed a darkened area and bruising on the toes with no dressing or bandage in place.
Failure to Implement Podiatry Foot Care Recommendations: A resident with ESRD, anemia, HF, DM, and impaired cognition had thick, brittle, discolored, painful toenails consistent with a fungal infection. The podiatry evaluation recommended clotrimazole cream, a foot pillow, lotion, appropriate footwear, and avoiding barefoot transportation, but the OSR showed these recommendations were not implemented or ordered. The resident reported pain and embarrassment related to the condition, and the DON and RNS acknowledged the recommendations were not followed through.
Failure to Provide Foot Care and Podiatry Access: A resident with severe cognitive and physical impairment, bed confinement, and dependence for personal care had markedly long toenails and no clear follow-through for podiatry services. Staff gave inconsistent accounts of who was responsible for nail care and arranging podiatry, and hospice staff stated the family was responsible for payment while the resident’s focus was on wounds rather than nail care.
Failure to provide timely foot care and arrange podiatry services for a resident with severe cognitive impairment and ADL dependence. Staff observed thick, jagged, and overgrown toenails that had been present for some time, but the condition was not identified or reported earlier. The resident had no documented podiatry consult until a provider order was finally obtained after the toenail condition was brought to staff attention.
A resident with DM, HTN, gout, edema, weakness, anemia, and obesity had a toe nicked and bleeding during a podiatry nail-trimming visit. The DON said the injury was not reported to her, there were no treatment orders, the facility did not follow up on the secure message or the physician response, and the podiatrist's notes were still unavailable. The resident's later physician note did not address the toe injury, and a subsequent nurse assessment noted discoloration under the nail bed.
Failure to Monitor and Treat Foot Skin Breakdown
Penalty
Summary
The facility failed to ensure a resident with impaired skin integrity received necessary care and treatment to promote healing of wounds on the bottom of the right foot. Resident #7 was admitted with diagnoses including aphasia, high blood pressure, hemiplegia and hemiparesis, and idiopathic peripheral neuropathy. The admission skin assessment noted two hard calloused areas on the bottom of the right foot, but there was no additional information such as size or color, and there was no evidence the physician was aware of the areas. The physician order required weekly skin evaluations and documentation under skin observations, with physician notification of new skin conditions every Tuesday for skin assessment. The medical record showed no additional skin assessments of the calloused areas and no evidence of any skin treatments being provided. During observation, the resident pointed to the right foot and implied pain; two white calloused areas approximately 1.5 cm in diameter were seen on the bottom of the foot, closed with no drainage. The RN stated the resident had come in with the areas and that she had been padding them to protect them while waiting for the doctor to see the resident, but at the time of observation there was no padding in place and nothing protecting the areas. Later interview with the RN confirmed no treatment had been started, the physician had not been notified, and no weekly measurements had been completed since admission. The facility policy required weekly tracking of all wounds on the Wound Tracking Worksheet.
Omitted Left Foot Treatment and Missed Podiatry Follow-Up
Penalty
Summary
Proper foot care was not provided for one resident who had been readmitted after a surgical procedure on the left thigh requiring a wound vac. The hospital discharge summary dated 05/12/26 indicated the resident also had a laceration to the 5th toe on the left foot with a treatment to be completed by nursing, and that a follow-up appointment with podiatry was needed because of fractures of the 4th and 5th left toes. The resident’s orders and care plan contained no treatment orders or care plan related to the left foot laceration, and the After Visit Summary listed only radiology and orthopedic surgery appointments related to the left thigh fracture/fixation. During the survey, staff were unable to confirm the left foot treatment. A CNA stated she was not sure whether the resident had a wound or bandage on the left foot, and an LPN stated she was not sure about a treatment or wound to the left foot. When the foot was observed, a darkened area was present on the inner aspect of the 5th left toe, bruising was present on the 4th and 5th toes, and there was no treatment or bandage in place. The DON acknowledged the treatment orders had been omitted and the podiatry appointment had not been scheduled. The NHA stated the facility did not have a podiatry policy because it did not have direct facility podiatry services.
Failure to Implement Podiatry-Recommend Foot Care
Penalty
Summary
The facility failed to implement the podiatrist-recommended treatment for Resident 23’s toenail fungal infection. Resident 23 was admitted with ESRD, anemia, heart failure, and DM, and the MDS indicated moderately impaired cognition with assistance needed for multiple activities of daily living. The OSR showed an order for a podiatry visit and topical treatments, but there was no order for clotrimazole, no order for a foot pillow, and no order to avoid barefoot transportation as recommended by the podiatrist. During observation, Resident 23’s toenails were noted to be brittle, thick, long, and blackish-yellow, and her feet were dry with skin flakes falling off when her socks were removed. Resident 23 stated she had seen the podiatrist a few months earlier but had not received any treatment for the fungal infection on her toenails. She also stated the toenails were painful when she stood up or when they were touched and that their appearance caused her embarrassment. The podiatry evaluation documented thickened, discolored, brittle, and painful toenails and recommended clotrimazole 1% cream daily, elevating the lower extremities with a foot pillow, applying lotion per facility protocol, providing appropriate footwear, and avoiding barefoot transportation. RNS 1 stated these recommendations should have been carried out and care-planned, while the SSD and DON stated staff had not followed through with the podiatrist’s recommendations and were unaware of the current condition of Resident 23’s toenails.
Failure to Provide Foot Care and Podiatry Access
Penalty
Summary
The facility failed to provide proper foot care and access to podiatry services for a resident who was dependent for personal care and had severe cognitive and physical impairment. The resident’s record showed diagnoses including severe weakness, weight loss/failure to thrive, muscle wasting, functional quadriplegia, bed confinement, encephalopathy, anxiety, and severe muscle weakness from critical illness. The MDS reflected a BIMS score of 0, and the resident had impairment in one upper extremity and both lower extremities. The care plan indicated the resident required substantial to maximal assistance with putting on and taking off footwear and with personal hygiene, and the physician orders included a podiatrist appointment order. During observation, the resident was noted to have toenails approximately 3 centimeters long while the fingernails were trimmed. Staff interviews showed inconsistent understanding of who was responsible for nail care and arranging podiatry services. An RN stated nursing rounds were done frequently and that nursing would make a wound care order and a podiatry order if needed, while also stating administration followed up when there was an order. A CNA stated that nurses were responsible for nail care and that CNAs reported concerns to nursing, but CNAs did not document nail care on the plan of care. Another CNA stated nurses and the podiatrist were responsible for nail care and that CNAs told nurses when residents needed nail care. The DON stated the nurse would print the podiatry information for the transportation person to make the appointment, and that the nurse was responsible for the hall to make sure it was getting done. The DON also stated that for hospice residents, hospice was responsible for podiatry, while the CNAs at the facility should still let staff know if a resident needed care. Hospice staff stated the family was responsible for paying the podiatrist and that the resident was a new admission, and one hospice RN stated the focus was on wounds and not nail care. The Administrator stated the process for podiatry on hospice patients was not clear and that if the resident got care, it would be voiced by anyone in the facility or hospice. The facility policy stated leadership would provide podiatry services for nail disorders and preventive foot care when indicated, and that the facility would assist residents in obtaining services if they were unable to choose their own podiatrist.
Failure to Provide Timely Foot Care and Podiatry Referral
Penalty
Summary
The facility failed to ensure appropriate foot care for a resident with severe cognitive impairment, non-Alzheimer's dementia, depression, COPD, muscle weakness, and a history of falling. The resident required substantial to maximum assistance with toileting hygiene, bathing, footwear, and some dressing and personal hygiene tasks, and his care plan did not address his ADL needs. Review of the medical record showed no podiatry consultation or documentation that he had been seen by a podiatrist from admission through the time the deficiency was identified. An observation showed the resident lying in bed with both feet exposed and his toenails in poor condition. The great toenails on both feet were thick and jagged, and the toenails on the second through fifth toes of both feet were long, extended past the toenail bed, and curved around the toes and toe pads. Staff interviews indicated that the resident’s toenails had been in this condition for some time, that NAs did not trim thick toenails, and that a podiatry referral was needed for a trim. A nurse reported she first learned of the toenail condition when it was brought to her attention and that a provider order for podiatry referral was then obtained. Additional interviews with the NA, DON, Social Services staff, and Administrator confirmed that staff had not identified and reported the toenail condition earlier. The DON stated the condition appeared longstanding and needed trimming, and the Administrator stated staff should have identified the condition on admission, during daily care, or during weekly skin audits. The record showed the podiatry referral order was entered only after the condition was recognized, and the Social Services staff member was still working to enroll the resident for the next facility podiatry clinic.
Failure to Monitor and Treat Toe Injury After Podiatry Visit
Penalty
Summary
The facility failed to ensure foot care, including monitoring and treatment, was provided after a resident's toe was cut during a podiatry visit. The resident had diagnoses including type 2 diabetes mellitus, hypertension, gout, edema, muscle weakness, anemia, and obesity. On 3/9/26, a secure conversation documented that the resident was seen by the podiatrist, her toenails were clipped, and the left big toe was bleeding and wrapped by the podiatrist. The communication also showed the nurse asked whether a Dremel or nail grinder could be used for future podiatry visits and asked if the nurse practitioner could look at the resident's toe, but the physician response was only to add the resident to his list. The DON stated she was not aware the toe had been cut and said it was not reported to her. She later stated there were no treatment orders for the cut toe, the facility did not follow up on the secure conversation or the physician's response, and skin checks and a proper treatment plan should have been in place because the resident is diabetic. The facility still did not have the podiatrist's notes from the visit. The resident's physician note from 4/9/26 did not mention the toenail care or toe injury. A skin alteration incident completed by the DON documented that the podiatrist nicked the resident's left foot and bleeding was noted, and the resident witnessed the provider nicking her left great toe during treatment. A nurse's note entered later showed the left great toe was assessed with no open areas, but black and yellow discoloration was noted under the nail bed.
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