Failure to Provide Timely Podiatry Care and Physician Notification Resulting in Amputation
Penalty
Summary
A resident with a history of intellectual disabilities, Down syndrome, Type II diabetes mellitus with circulatory complications, peripheral vascular disease, and acute osteomyelitis was admitted and readmitted to the facility. The resident was care planned for risks related to fragile skin and peripheral vascular disease, with interventions including monitoring for injury, infection, and ulcers, and education on proper foot care. Despite being scheduled for podiatry services, the resident was not seen as planned, and there was no documentation or explanation for the missed appointment. Additionally, there were no wound care orders in place for the months leading up to the incident. On one occasion, the resident complained of pain in his right foot, and a nurse noted a small opening and swelling on the third toe. The nurse cleansed the area and applied a topical antibiotic and bandage but did not document notifying the physician, nurse practitioner, or responsible party, nor did they complete a change in condition form or incident report. There was no evidence of further assessment or physician notification until several days later, when the resident requested evaluation from a nurse practitioner due to ongoing pain. At that time, the toe was found to be ischemic, macerated, with foul odor and exposed bone, leading to the resident being sent to the hospital, where gangrene and diabetic foot infection were diagnosed, resulting in amputation of the third toe and, later, the remaining toes on the right foot. The resident, who had previously been independent with ambulation and activities of daily living, became wheelchair-dependent following the amputations. Interviews with staff revealed a lack of recall regarding proper notification and documentation procedures, and personnel files showed no evidence of completed training or competencies related to wound care, change in condition, or physician notification. Facility policies required timely notification of changes in resident condition, but there was no documentation that these procedures were followed in this case. The failure to provide timely podiatry care and to accurately and thoroughly report and address the resident's change in condition resulted in significant harm, including loss of all toes on the right foot and decreased mobility.