Failure to Provide Ordered Foot and Nail Care Resulting in Painful Overgrown Toenails
Penalty
Summary
The facility failed to provide appropriate foot and nail care to one resident who had a physician’s order for routine nail care. The resident was admitted with hemiplegia/hemiparesis affecting the left side and peripheral vascular disease, and was assessed as cognitively intact on the MDS, requiring substantial/maximal assistance with bathing and supervision/touching assistance for personal hygiene. A physician’s order dated 5/12/24 directed that nail care could be provided once every four weeks on Sundays, but the resident’s left toenails were observed to be very long, overgrown past the tips of the toes, sharp-edged, dirty, and discolored yellow and dark brown, and had not been trimmed for several months. During observation and interview, the resident was noted to be wearing a sock and shoe only on the right foot, with the left foot bare. The resident reported having repeatedly asked staff to trim his toenails and stated he could not wear a sock or shoe on the left foot because the long toenails caused pain when he tried. The resident further reported that CNAs and licensed nurses told him they could not cut his toenails and that he would be charged $50 for the service. CNA staff confirmed that the resident’s toenails were long, sharp, discolored, and had not been trimmed for a long time, and stated that when a resident refused hygiene care, they were expected to notify the nurse so the nurse could encourage cooperation and explain risks. Interviews with nursing and social services staff showed that the facility had processes for nail care and podiatry services that were not followed for this resident. The LN stated that podiatry visited monthly and that residents could be added to the podiatry list based on nursing assessment or CNA reports, and that LNs could trim toenails with a doctor’s order, with refusals documented in progress notes and the physician notified. The Social Services Director reported that the resident was not on the podiatry list and had no record of prior podiatry visits. The DON confirmed there were no progress notes or other documentation of the resident refusing toenail care, despite staff claims of refusal, and verified the existence of the standing nail care order and the poor condition of the resident’s toenails. Facility policies on ADLs and nail care required provision of hygiene and nail care, consultation with an RN for special directions, and documentation of nail care provided, which were not carried out in this case.
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