Failure to Provide and Document Diabetic Foot Care
Penalty
Summary
The facility failed to provide appropriate diabetic foot care for two of three sampled residents who were at risk for diabetes-related foot complications. For one resident with Type 2 Diabetes Mellitus and diabetic neuropathy, the Treatment Administration Record (TAR) indicated an order for daily diabetic foot care and documentation of abnormal findings. However, on three consecutive days, the assigned nurse did not provide the ordered care, citing lack of time, and failed to document the omission in the resident's medical record. On a subsequent day, another nurse signed off that the care was completed but later admitted she had not performed the care herself, instead instructing a Certified Nurse Aide (CNA) to apply lotion to the resident's feet and legs. The CNA confirmed she applied lotion as directed. For a second resident with Type 2 Diabetes Mellitus and Alzheimer's Disease, there was no documentation that nursing staff obtained a physician's order for nightly diabetic foot care upon admission, nor evidence that such care was provided. The Director of Nurses (DON) confirmed that diabetic foot care should include cleaning, inspecting, and moisturizing the feet, with proper documentation and communication of findings, and acknowledged that a physician's order should have been obtained for this resident.