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F0684
D

Failure to Implement Podiatry Recommendations and Complete Weekly Skin Assessments

South Hadley, Massachusetts Survey Completed on 05-27-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide treatment and care in accordance with professional standards of practice for a resident who required podiatry services and weekly skin assessments. After a podiatrist examined the resident and removed a toenail from the right great toe, recommendations were made for wound care, including cleansing with sterile saline, applying topical antibiotic, and monitoring for infection. However, these recommendations were not implemented, as there were no treatment orders in place for the resident's right great toe, and the physician assistant was not notified of the podiatrist's recommendations. The resident reported that staff had not checked or changed the bandage since the podiatrist's visit. Additionally, the facility failed to perform weekly skin assessments as ordered for the resident. Documentation showed that weekly skin checks were missed on two consecutive Saturdays, and staff interviews confirmed that the assessments were not completed. The lack of skin assessments contributed to the failure to identify and address the wound on the resident's toe, as staff were unaware of the bandage and the need for follow-up care.

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