Failure to Assess and Monitor Toenail Detachment in High-Risk Resident
Penalty
Summary
A deficiency occurred when the facility failed to comprehensively assess and monitor a resident's toenail detachment after it began bleeding for five days. The resident, who had multiple diagnoses including diabetes, chronic obstructive pulmonary disease, dysphagia, and was on long-term anticoagulant therapy, was dependent on staff for all activities of daily living and had impaired cognitive skills. The resident's daughter reported bleeding from the resident's toe, and an RN noted dried blood under the left fifth toe. The RN notified the physician, who ordered the treatment nurse to assess and evaluate the situation. Despite this order, there was no documentation of ongoing assessment or monitoring of the toe's condition in the days following the initial report. The RN who first assessed the resident was not present for six days, and upon return, found the toenail had completely detached. The treatment nurse only assessed the resident after the toenail was fully removed, and there was no follow-up treatment documentation regarding the bleeding or the status of the toe during the intervening period. The Director of Nursing confirmed that there was no documentation regarding the status of the toenail's detachment after the initial change of condition assessment. Interviews with nursing staff, including the LVN and Assistant Director of Nursing, confirmed that the resident's condition warranted close monitoring and documentation due to the risk factors of diabetes and anticoagulant use. Facility policies required documentation of changes in condition for at least 72 hours or longer if warranted, including objective, complete, and accurate records of assessments and treatments. However, these policies were not followed, as there was no documentation of the source of bleeding, circulation, signs of infection, or the progress of the toenail detachment for several days.
Plan Of Correction
Immediate Corrective Action Upon notification, the RN Supervisor immediately assessed the toenail of Resident 2 and notified the Physician and family. The treatment nurse was informed and assessed the resident. On 7/9/25, the DON gave a 1-1 in-service to RN 1 regarding ensuring to assess and monitor residents after they have a change of condition and ensure not to delay necessary medical intervention, pain, or further injury. On 7/9/25, the DON gave a 1-1 in-service to LVN 1 regarding ensuring to assess and monitor residents after they have a change of condition and ensure not to delay necessary medical intervention, pain, or further injury. Identification of Others at Risk The Director of Nursing and Medical Records conducted a health records review on 7/9/2025 to ensure all residents with a change of condition were assessed and monitored and follow-up was completed. No other residents were identified with the same deficient. Process to Prevent Recurrence On 7/9/25, the DON gave an in-service to Licensed nurses regarding ensuring to assess and monitor residents after they have a change of condition and ensure not to delay necessary medical intervention, pain, or further injury. Medical Records will audit change of condition assessments daily for six weeks and weekly thereafter for three months to ensure compliance. All findings will be reported to the DON. Monitoring Performance The DON or designee will randomly check residents' change of condition assessments several times a week for six weeks and weekly thereafter for three months to ensure licensed nurses have assessed and monitored after the residents' change of condition.