Failure to Provide Timely and Appropriate Foot Care and Podiatry Services
Penalty
Summary
The facility failed to provide necessary foot care and treatment in accordance with professional standards for three residents with diabetes and other complex medical conditions. One resident, who was cognitively intact and dependent on staff for lower extremity care, had not received podiatry services since admission, despite having a history of ingrown toenails and visible debris on the toenail bed. Staff interviews confirmed that diabetic residents should be referred to podiatry upon admission and seen quarterly, but this did not occur. Another resident, also cognitively intact with diabetes, had a significant gap in podiatry follow-up after an initial consult, with staff acknowledging that recommended follow-up visits were missed due to issues with the previous podiatrist and delays in arranging new services. A third resident with heart failure, end-stage kidney failure, diabetes, and a diabetic foot ulcer had multiple recommendations from a consulting wound provider and a physician's order for a podiatry referral, but there was no documentation that the referral was completed or that the resident was seen by a podiatrist. Staff confirmed that the resident had not received podiatry services as recommended, citing ongoing issues with arranging podiatry care. These findings were based on observations, interviews, and record reviews, and demonstrate a failure to ensure timely and appropriate foot care for residents at risk.