Failure to Implement Comprehensive Care Plan for Diabetic Foot Ulcer
Penalty
Summary
The facility failed to implement a comprehensive care plan for a resident with a diabetic foot ulcer. During wound care observation, the resident was found to have an open ulcer on the left lateral foot, which was being treated according to physician orders. The resident's medical record showed a history of hemiplegia, hemiparesis, cognitive communication deficit, and type 2 diabetes mellitus, with severe cognitive impairment and dependence on staff for all activities of daily living. The resident had a recurring diabetic foot ulcer that had healed and reopened multiple times, with the most recent reopening documented in the clinical notes. Despite ongoing wound care and recommendations for pressure reduction and repositioning, the resident's record did not contain a comprehensive care plan specifically addressing the diabetic foot ulcer. The existing care plan only addressed general risk for skin integrity issues and did not include specific interventions for the current wound. The Director of Nursing confirmed that there was no care plan in place for the diabetic foot ulcer at the time of the survey, despite the wound being open and under treatment.