Failure to Monitor and Document New Wound Following Podiatric Procedure
Penalty
Summary
The facility failed to complete appropriate monitoring and documentation for a resident who experienced a new skin avulsion on the left second toe following podiatric treatment. The resident, who had diagnoses of diabetes mellitus and peripheral vascular disease, was noted to have a new wound on August 18, 2025, as documented in the skin check. However, subsequent skilled evaluations on August 19 and August 21, 2025, did not identify any skin issues, indicating inconsistent evaluation of the wound. The Treatment Nurse confirmed that the skin avulsion was a new finding and should have been treated as a change of condition, requiring documentation and ongoing monitoring to track the wound's progress. Interviews with facility staff, including the DON, revealed that the wound was not monitored every shift for three days as required by facility policy for a change of condition. The facility's policy states that significant changes in a resident's condition require interdisciplinary review and thorough documentation. The lack of consistent monitoring and documentation for the resident's new wound resulted in a deficiency related to the facility's failure to provide care and treatment according to orders, resident preferences, and goals.