Failure to Develop and Implement Comprehensive Care Plan for Diabetic Foot Ulcer
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and implemented to address a resident's diabetic foot ulcer and history of foot wounds. Documentation showed that the resident, who had a history of diabetes, neuropathy, and previous toe wounds, presented with new open and scabbed areas on the right toes. Despite these ongoing and new issues, the care plan did not reflect the resident's history of foot sores or provide specific preventative interventions for diabetic foot ulcers. The care plan was not updated to include the diagnosis of a diabetic ulcer until several months after the condition was identified, and interventions specific to the ulcer were only added after a significant delay. Interviews with staff revealed that nurses were responsible for updating care plans when new issues were identified, and that preventative measures should be included in the care plan. However, the care plan for this resident lacked documentation of the resident's history of foot problems and did not guide staff on preventative care for diabetic foot ulcers. Staff also indicated that changes to care plans were communicated during shift reports, but the care plan still failed to include necessary information to direct care for the resident's ongoing and current foot issues.