Failure to Provide Adequate Foot Care Due to Incomplete Documentation and Communication
Penalty
Summary
The facility failed to provide adequate foot care for a resident with a history of traumatic brain injury, aphasia, and cognitive deficits. The resident was noted to have self-care deficits and was frequently resistive or combative during attempts at nail care, both by staff and an outside podiatrist. Despite repeated refusals, there was no documentation that the resident's family was notified of the ongoing issue, nor was there evidence that refusals were discussed during care conferences. Observations revealed the resident's toenails were extremely long, thick, and curled, and staff interviews confirmed awareness of the resident's refusal and the lack of a clear plan to address the situation. Medical record reviews showed multiple missed opportunities to document and communicate the resident's refusals and the resulting condition of her toenails. The facility's policy required ensuring proper foot care, but interventions such as reapproaching the resident or educating the family were not consistently documented or implemented. The podiatrist suggested the possibility of sedation to facilitate nail care, indicating the chronic nature of the problem, but there was no evidence that this recommendation had been acted upon or communicated to the family.