Failure to Refer Resident for Wound Care as Ordered by Podiatrist
Penalty
Summary
The facility failed to follow physician orders regarding foot care for one resident who had a wound on the left dorsal forefoot, as identified during a podiatry evaluation. The podiatrist documented the presence of a 3x3 cm wound, applied a dressing, notified nursing staff, and instructed that wound management be deferred to the wound care physician. The podiatrist also indicated that if further recommendations were needed from a podiatry standpoint, a specific reconsult should be requested. Despite these instructions, there was no documentation that the resident was referred to the wound care physician as ordered. Both the treatment nurse and the DON confirmed during interviews and record reviews that they could not provide evidence of a referral or that the wound care physician had been notified. The facility's policy requires that residents receive foot care and treatment in accordance with professional standards, including the management of medical conditions to prevent complications, but this was not followed in this instance.