Failure to Identify, Document, and Treat Diabetic Foot Ulcer Resulting in Amputation
Penalty
Summary
A facility failed to properly identify, assess, document, and treat a diabetic foot ulcer for a resident with a history of diabetes, neuropathy, and previous toe wounds. The physician initially identified a wound on the resident's right great toe in June, but the facility did not document or add this wound to the resident's diagnoses or care plan until several months later. Despite the resident's high risk for skin breakdown and a documented history of toe wounds, the care plan and interventions were not updated in a timely manner to address the new ulcer. Weekly skin assessments conducted by nursing staff repeatedly failed to identify or adequately document the right great toe wound, even after it was noted by the physician. There were inconsistencies and omissions in the administration of prescribed treatments, such as Mupirocin ointment, which was not administered as ordered in June and July. When the resident was sent to a wound care clinic, the facility failed to provide necessary documentation or communicate the specific concerns, resulting in the clinic being unaware of the wound and unable to provide targeted care. Additionally, there were delays in implementing wound care orders, with a nine-day gap between the order for Thera honey and PolyMem dressings and the start of treatment. Throughout the course of the resident's care, there was a lack of effective communication and follow-through among facility staff regarding the resident's wound status and treatment needs. Progress notes, skin assessments, and notifications to providers were incomplete or missing, and the resident's worsening condition was not promptly addressed. The failure to identify, monitor, and treat the diabetic ulcer led to the deterioration of the wound, resulting in hospitalization and amputation of the resident's right great toe.