Failure to Develop Care Plan for Left Foot Treatment
Penalty
Summary
The facility failed to develop a care plan addressing left foot treatments for a male resident admitted with multiple diagnoses, including peripheral vascular disease, Type 2 diabetes mellitus, atherosclerosis, and other chronic conditions. The resident was identified as being at risk for developing a pressure injury and was dependent on staff for activities such as toileting, personal hygiene, and transfers. Despite a physician's order to apply A&D ointment to the resident's left foot and toes for excessive dryness and to monitor for skin breakdown, no care plan was created to address these specific needs. During an interview and record review, the DON confirmed that the left foot treatment order should have been care planned, especially given the resident's risk factors for pressure injuries. The facility's own policies required comprehensive, interdisciplinary care planning for prevention and wound treatments, as well as regular review and updates to care plans based on changes in resident condition. However, the care plan for this resident did not include interventions for the left foot, and the omission was acknowledged by facility leadership.