Failure to Provide Ordered Medical Treatment for Resident's Toe Infection
Penalty
Summary
A resident with moderate intellectual disability and dementia was admitted to the facility and developed a discolored and tender right great toe. The facility physician was notified, and a verbal order was given to start Epsom salt soaks for the affected toe. The order was later updated to continue the soaks and add an antibiotic due to signs of infection, including erythema and open drainage. Documentation in the medication administration record indicated that the foot soak was completed as ordered on the evening shift; however, multiple staff statements and facility investigation revealed that the treatment was not actually performed during that shift. Further review showed that the resident was present in common areas during the time the soak was supposed to occur, and staff who were present did not witness the treatment being provided. Additionally, a nursing assistant noted that the bandage on the resident's toe appeared used and dry, inconsistent with a recent soak. The facility's investigation concluded that it was more likely than not that the ordered foot soak was not completed as documented, resulting in a failure to provide medical care as ordered and a possible diminished quality of life for the resident.