Failure to Ensure Timely Podiatry Care for Resident with Toe Infection
Penalty
Summary
A resident with diabetes and polyneuropathy, who was dependent on staff for personal care and had a history of memory recall deficits, developed redness, swelling, and pain in the left great toe. The care plan required daily foot checks and prompt reporting of any abnormalities. After a family member reported the toe issue, an Advanced Practice Registered Nurse (APRN) evaluated the resident, diagnosed an infection, and ordered antibiotics, warm soaks, and a podiatry consult. The APRN also directed that the resident be placed on the podiatrist's priority schedule for an upcoming visit. Despite these orders, the facility failed to ensure the resident was added to the podiatrist's priority list. Although the scheduling secretary reported emailing the podiatry office to include the resident, the facility's podiatry list for the scheduled visit did not reflect the resident's name. As a result, the resident was not seen by the podiatrist as intended. Interviews with facility staff and the podiatrist confirmed that the resident should have been prioritized and that Medicare coverage was not a barrier to timely care.