Failure to Review and Assess Plan of Care for Resident with New PVD Diagnosis
Penalty
Summary
The facility failed to ensure that the Medical Director reviewed the total plan of care and conducted an appropriate assessment for a resident newly diagnosed with peripheral vascular disease (PVD). The resident, who had a history of diabetes mellitus, dementia, multiple contractures, malnutrition, hemiplegia, and PVD, was severely cognitively impaired and unable to make decisions independently. A podiatrist had previously documented absent pedal pulses, delayed capillary refill, and pigmentary changes in both feet, and diagnosed the resident with PVD, recommending routine or at-risk foot care but not vascular surgery referral. Despite these findings, the Medical Director did not examine the resident's feet or assess pedal pulses during a subsequent visit and was unaware of the podiatrist's consultation and the new PVD diagnosis. Nursing staff could not confirm whether the Medical Director had been notified of the podiatrist's findings or the new diagnosis. The Medical Director's progress notes did not address the recent PVD diagnosis or include a follow-up plan, indicating a lack of communication and review of the resident's updated care needs.