Failure to Provide Ordered Diabetic Foot Care
Penalty
Summary
The deficiency involves the facility’s failure to provide physician-ordered diabetic foot care for one resident with multiple high-risk conditions. The resident was admitted with Type 2 diabetes mellitus with diabetic autonomic neuropathy, paraplegia, cognitive communication deficit, reduced mobility, and unsteadiness on feet. Review of the resident’s care plan dated 08/05/25 showed that diabetic foot care was not included. A physician order dated 09/11/25 directed daily diabetic foot care and checks, including observation of the feet, toes, ankles, and soles for alterations in skin integrity, color, temperature, and cleanliness, inspection of shoes for proper fit and excessive wear, and checking pedal pulses every night shift. Review of the Treatment Administration Record from 09/11/25 through 01/14/26 revealed that the ordered diabetic foot care was not completed by nursing staff for the entire period reviewed. A podiatry consultation on 01/14/26 documented diagnoses of Type 2 diabetes mellitus with hyperglycemia, onychogryphosis, nail dystrophy, pain in both toes, localized edema, and slightly diminished range of motion in the foot and ankle joints without pain. The podiatrist performed debridement and trimming of thickened, painful toenails and recommended daily foot checks, supportive shoes, and moisturizing lotions with precautions. During an interview on 01/22/26, the DON stated it was her expectation that physician orders, including diabetic foot care, be followed and confirmed that the ordered foot care for this resident was not followed as prescribed.
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