Failure to Identify and Manage Diabetic Foot Ulcer Leads to Amputation
Penalty
Summary
Facility staff failed to ensure that nurses and nurse aides possessed the necessary competencies and skills to identify, assess, document, and monitor a diabetic ulcer for one resident. Despite a physician's note documenting a diabetic ulcer on the resident's right great toe, weekly head-to-toe skin checks performed by facility staff throughout July failed to identify any skin issues. The first documentation of a skin alteration on the right great toe did not occur until early August, well after the physician's initial identification. Additionally, the medication administration record for July and August did not show evidence that staff administered the prescribed Mupirocin ointment as ordered by the physician. Interviews with staff revealed inconsistent practices and a lack of formal wound care training among nursing staff. One staff member admitted that skin issues might be missed depending on the thoroughness of the assessment and noted that formal wound care training was lacking, aside from wound vac training. Documentation and follow-up with the physician were also insufficient, as there was no evidence of ongoing monitoring or communication regarding the resident's diabetic foot ulcer after its initial identification. Ultimately, the resident required hospitalization and amputation of the right great toe after a wound care appointment, due to the facility's failure to provide necessary services for early identification, ongoing treatment, and preventative interventions.