Failure to Document and Address Insects Found on Resident's Foot
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's foot was free of insects. The resident, who was alert and had a care plan for an open lesion between the 4th and 5th toes of the right foot, was observed by a podiatrist to have a 'family of insects' in the webspace of the affected toes. The podiatrist reported this finding to a nurse, who then cleansed the area but did not document the presence or removal of insects in the resident's medical record. The care plan for the resident included regular wound care, skin assessments, and monitoring for signs of infection, but there was no documentation of insects or maggots in the resident's records prior to or after the podiatrist's observation. Multiple staff interviews revealed inconsistent awareness and documentation regarding the presence of insects. The nurse who was informed by the podiatrist admitted to assessing and cleaning the area but did not record the incident, citing being busy and forgetting to document. Other staff, including the acting wound nurse and the DON, stated that they did not observe insects or maggots and were not informed by other staff of such findings. The wound nurse also noted a lack of access to the podiatrist's notes, which contributed to incomplete information in the resident's record. The facility's documentation policy requires that all services provided, changes in condition, and unusual findings be recorded in the resident's medical record, including the date, time, and name of the person providing care. Despite this policy, the presence of insects was not documented at the time of the incident, and the only mention was an addendum added by the podiatrist several days later. This failure to document a significant change in the resident's condition resulted in an incomplete and inaccurate medical record.