Failure to Timely Assess, Treat, and Document Resident's Foot Injury and Allergy
Penalty
Summary
Facility staff failed to provide timely and adequate assessment and treatment for a resident who sustained a toe and skin injury. The resident, who had a history of chronic kidney disease, diabetes, and allergies to sulfa antibiotics, reported that their right foot was run over by another resident in a wheelchair. Despite physician orders for weekly skin assessments, documentation showed that these assessments were not consistently completed, with only one assessment documented in the month following the injury. Progress notes also lacked documentation of skin assessments during the critical period after the injury. When the resident reported pain and swelling in the right foot, staff contacted the physician and received a verbal order for a mobile X-ray. However, the X-ray was not obtained until four days after the order was placed, despite repeated requests from the resident and their family. During this period, the resident's condition worsened, with increased swelling, redness, and the development of an open, necrotic area on the toe. Staff interviews revealed confusion about responsibility for wound and skin assessments, and delays in both assessment and treatment were noted. Additionally, staff administered Bactrim DS, an antibiotic containing sulfa, to the resident despite a documented allergy to sulfa antibiotics. The medication was given on multiple occasions before being held after the resident's family raised concerns. The resident ultimately required hospitalization for evaluation and treatment of the foot injury, which was later diagnosed as a toe fracture with infection. Throughout the incident, there were multiple failures in timely assessment, documentation, communication, and adherence to physician orders and resident-specific allergies.