Failure to Notify Family of New Diabetic Foot Ulcer
Penalty
Summary
The facility failed to notify the family representative of a resident regarding the development of a diabetic foot ulcer. Clinical record review showed that the resident, who had moderate cognitive impairment and diagnoses including dementia, coronary artery disease, and diabetes mellitus, did not have any wounds or skin problems documented on the Minimum Data Set (MDS) assessment. However, an electronic health record entry from a wound physician documented a new full-thickness diabetic wound on the resident's left medial heel. The family representative reported that they were not informed by the facility about the wound and only became aware of it when the wound care provider visited the resident. Interviews with facility staff, including the MDS Coordinator and the Assistant Director of Nursing (ADON), confirmed that the expectation was for nursing staff to notify the family of any new wounds or changes in condition on the same day and to document this notification in the progress notes. Review of the facility's policy also required notification of the resident's representative within 24 hours of a significant change in the resident's condition. Despite these policies and expectations, there was no evidence that the family was notified of the new wound as required.