Failure to Provide Proper Foot and Wound Care
Penalty
Summary
The facility failed to provide appropriate foot and wound care for a resident with a wound on the great toe and a blister on the second toe. The resident, who had severe cognitive impairment and multiple diagnoses including epilepsy, stroke history, and muscle weakness, was identified as being at risk for skin breakdown. Despite this, the facility did not document or treat the wounds according to professional standards and the facility's own foot care policy. The great toe wound was first noted during a shower, but a comprehensive skin assessment was not completed at that time, and the second toe blister was not documented in subsequent skin assessments. There were no treatment orders for either the great toe wound or the second toe blister in the resident's physician orders summary. Progress notes indicated that the DON believed she had received an order to leave the wound open to air, but the resident's physician and nurse practitioner were unaware of the wounds and had not given such orders. The wound was left uncovered and untreated for several days, and the first documented treatment occurred only after the wound became infected. The wound management company was not consulted until after the infection developed, and the wound nurse expected the wound to have been covered to prevent infection. Documentation on skin monitoring shower sheets and the facility's wound report failed to include the second toe blister, and the great toe wound was inconsistently noted. Interviews with staff revealed a lack of awareness and incomplete assessments, with the LPN unaware of the blister and the DON acknowledging that a thorough assessment and treatment order should have been obtained when the wound was first discovered. The resident's family was also not fully informed about the extent of the wounds.