Failure to Monitor and Document Diabetic Foot Care
Penalty
Summary
A diabetic resident with multiple comorbidities, including hemiplegia, vascular disease, and immobility, was admitted to the facility and identified as being at high risk for skin breakdown. The resident's care plan included regular skin and foot inspections as per facility protocol, and the podiatrist provided recommendations for daily foot care and monitoring. Despite these interventions, documentation and interviews revealed that routine skin checks, particularly of the feet, were either not performed adequately or not documented accurately by nursing staff and CNAs. Over the course of a month, no skin alterations were recorded, even though the resident was dependent on staff for mobility and hygiene and at high risk for ulcers. On assessment, the resident was found to have developed a necrotic diabetic ulcer on the left heel, which was not identified until it had progressed to a significant size with 100% hard eschar. The wound required a vascular consultation for possible surgical intervention. Staff interviews confirmed that the wound should have been detected earlier, and the facility's own policies required daily skin assessments and prompt reporting of changes, especially for residents with diabetes and vascular disease. The failure to monitor and document the resident's foot condition in accordance with professional standards and facility policy led to the development and progression of the necrotic ulcer.