Failure to Provide Proper Foot Care and Implement Physician Orders
Penalty
Summary
A resident with a history of diabetes, peripheral vascular disease, and left foot pain was not provided with appropriate foot care in accordance with professional standards. Despite having physician orders for a bed cradle to prevent bedding from resting on the resident's feet and referrals for podiatry and vascular evaluations, the resident was repeatedly observed with blankets directly on their feet and heels on the mattress. The bed cradle, intended to alleviate pain and prevent further complications, was not in use as ordered, and staff were unaware of how to use it or failed to offer it to the resident. Documentation on the Treatment Administration Record inaccurately indicated that the bed cradle was in use every shift, even though it had only recently arrived and was not being applied as required. The resident expressed ongoing pain and concern about their feet, specifically noting a blackened toenail and edema, which were observed by the surveyor. The medical record showed only one podiatry visit since admission, despite ongoing orders for podiatry care. Interviews with nursing staff and the DON confirmed a lack of clarity regarding podiatry visits and the use of the bed cradle, as well as improper documentation practices. These actions and inactions resulted in the resident not receiving the necessary foot care and interventions to maintain foot health and prevent complications related to their medical conditions.