Failure to Provide Routine Diabetic Foot Checks
Penalty
Summary
The facility failed to provide routine diabetic foot checks as required by physician orders and facility policy for two residents with diabetes. For one resident with type 2 diabetes, diabetic polyneuropathy, and a history of pressure ulcers, the care plan and physician orders specified daily foot checks at bedtime. However, documentation showed that foot checks were not completed or signed off on several dates, and there was no documentation of foot checks prior to the initiation of the order. Interviews with nursing staff and the interim director of nursing confirmed that if the checks were not documented, they were not done, and that nightly foot checks were expected. For another resident with diabetes and a recent ankle fracture, physician orders and the treatment administration record also required nightly diabetic foot checks. Review of the records revealed multiple dates across several months where foot checks were not completed. An LPN interviewed could not recall specific details about the resident's foot checks and admitted that checks were sometimes rushed due to the resident's agitation. Additionally, a dressing placed by podiatry remained unchanged for several days, despite documentation indicating that foot checks had been completed. The interim director of nursing confirmed that foot checks should be completed and documented as ordered, and that any abnormalities should be recorded in a progress note.