Failure to Implement Interventions to Prevent Diabetic Wound
Penalty
Summary
The facility failed to implement necessary interventions to prevent the development of a diabetic wound for a resident with multiple risk factors, including diabetes, limited mobility, malnutrition, and dementia. The resident was assessed as cognitively impaired, required substantial assistance with hygiene and bed mobility, and had a history of pressing their feet against the bed's footboard, which was observed by staff and confirmed by the resident. Despite a physician's order to apply multi-podus boots to both feet while in bed to relieve pressure, the resident was observed not wearing the boots, and the care plan did not address the risk of developing diabetic ulcers to the lower extremities. Clinical documentation revealed that discoloration on the resident's right heel was first noted, and subsequent wound assessments identified the wound as being related to the resident's diabetes and pressure from the footboard. The wound progressed, requiring debridement and antibiotic therapy after becoming infected. Staff interviews confirmed awareness of the resident's behavior of sliding down in bed and pressing their feet against the footboard, which contributed to the wound's development. The wound physician emphasized the importance of proper footwear and positioning to prevent further injury, noting that the wound may not heal due to the resident's chronic conditions and ongoing risk factors. Observations and interviews indicated that the resident was not consistently using the prescribed multi-podus boots, and staff acknowledged the connection between the lack of proper offloading and the development of the wound. The facility's failure to update the care plan to address the resident's risk for diabetic ulcers and to ensure consistent implementation of physician-ordered interventions directly contributed to the resident developing a significant wound that required advanced medical intervention.