Failure to Provide Timely Podiatry Follow-Up and Foot Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate foot care and assist with podiatry appointments for one resident. The resident was admitted with diagnoses including type 2 diabetes mellitus, dementia, and anxiety disorder. An MDS assessment indicated the resident had no cognitive impairment in decision-making but required staff assistance with bathing, dressing, toileting, oral, and personal hygiene. A physician order dated 12/26/2025 authorized the resident to consult with a podiatrist. During an interview, the resident’s family member reported the resident’s toenails were turning dark brown and peeling, and stated that when this was brought to the DON’s attention, the DON said the resident would need to be seen by a podiatrist. Record review showed that during a podiatry visit documented as a Nursing Home Visit on 10/12/2025, the podiatrist noted dystrophic and elongated toenails and recommended routine foot care again in 60 days. The social services assistant confirmed that this was the resident’s last podiatry visit and that the resident was not seen again in 60 days as recommended. The assistant explained this did not occur due to a change in the resident’s insurance and the resident’s name being placed on the wrong podiatry list. The facility’s foot care policy stated that residents receive appropriate care and treatment to maintain mobility and foot health, which was not followed in this case.
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