Failure to Implement Podiatry Recommendations and Manage Blood Glucose for Wound Healing
Penalty
Summary
The facility failed to implement podiatry recommendations for wound care and diabetic management for a resident with multiple risk factors, including diabetes, peripheral vascular disease, decreased mobility, and existing wounds to the foot and heel. Despite repeated podiatry consults recommending specific wound care protocols and maintaining blood glucose levels below 180 mg/dl to promote healing, the facility did not follow through with these recommendations. Clinical records showed that the resident's blood glucose levels were consistently above the recommended range, with 39 out of 43 entries exceeding 180 mg/dl after the recommendations were made. There was no documented evidence that the physician was notified of the resident's persistently elevated blood glucose levels, nor were there any documented attempts to modify nutritional or pharmacological interventions to address the issue. The resident's condition worsened, resulting in a wound infection and subsequent hospital admission for osteomyelitis. The Director of Nursing confirmed that the podiatry recommendations for diabetic management were not addressed and that staff did not notify the physician of the elevated blood sugar levels.