Failure to Notify Physician of Change in Condition Resulting in Amputation
Penalty
Summary
A deficiency occurred when facility staff failed to immediately notify a resident's physician of a significant change in the resident's physical condition. The resident, who had a history of intellectual disabilities, Down syndrome, Type II diabetes mellitus with circulatory complications, peripheral vascular disease, and acute osteomyelitis, reported pain in his right foot. Upon assessment by a nurse, a small opening and swelling were noted on the third toe of the right foot, but there was no documentation that the physician, nurse practitioner, or responsible party were notified of this change. The nurse applied topical antibiotic ointment and a bandage without obtaining an order or further escalating the issue. The resident was not seen by the scheduled podiatrist, and there was no documentation explaining the missed appointment. Over the following days, the resident's condition worsened, and it was only after the resident requested an evaluation from the nurse practitioner that a full assessment was conducted. At that time, the third toe was found to have black eschar, maceration, foul odor, and exposed bone, leading to the resident being sent to the hospital. The resident subsequently underwent amputation of the third toe, and later, the remaining toes on the right foot due to ongoing infection and complications. The resident, who had previously been independent in ambulation, became wheelchair-bound as a result. Record reviews and interviews revealed a lack of documentation regarding timely physician notification, absence of wound care orders prior to the incident, and no evidence of staff following up on the resident's change in condition. Staff interviews indicated poor recall of the incident, lack of use of change in condition forms, and no clear communication with the physician or responsible party. Additionally, there was no evidence of staff training or competency checks related to change in condition, wound care, or physician notification in personnel files. The facility's policies did not provide specific guidance on wounds, skin, or foot problems, and there was no documentation of appropriate notifications or interventions at the time of the resident's decline.