F0684

G

Failure to Identify Skin Risk and Prevent Severe Diabetic Foot Wound

Marion, Indiana Survey Completed on 02-26-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to identify a resident’s risk for skin breakdown and to develop and implement interventions to prevent the development of significant foot wounds. The resident had multiple diagnoses including vascular dementia, hemiplegia and hemiparesis, type 2 diabetes mellitus, morbid obesity, chronic respiratory failure, chronic heart failure, COPD, peripheral autonomic neuropathy, and prior toe amputations. A quarterly MDS indicated the resident was cognitively intact and at risk for pressure ulcers, with pressure-reducing devices in use. Existing care plans addressed potential for skin impairment and non-compliance with care, but the clinical record did not document that the resident picked at his skin or used implements to cut his skin or wounds. A Braden Scale assessment in January indicated he was not at risk for pressure injuries, and a weekly skin observation on 2/7/26 documented intact skin with no foot concerns.

In the days leading up to the discovery of the wound, documentation showed incomplete or limited skin assessments. On 2/13/26, the resident refused a shower, and a nurse’s note indicated he did not feel well enough to shower and signed a refusal form. A shower sheet for that date indicated a full body check was completed with no concerns noted, and a CNA later reported that on that date there were no foot concerns other than a scab where a toe had been amputated, and nothing on the ball of the foot. A late-entry weekly skin observation note for 2/14/26, written on 2/19/26, indicated the resident’s skin was within normal limits but also stated he refused his shower and the skin assessment with the shower, so his feet were not assessed; it also noted he had calloused areas to his feet prior to that date. The facility’s policy required that each resident be observed for skin breakdown daily during care and on the assigned bath day by the CNA, with changes promptly reported to the charge nurse for detailed assessment.

On 2/16/26, the resident’s family member approached the nurse’s station demanding that someone examine the resident’s left foot, prompting discovery of multiple wounds. The nurse practitioner and facility nurse found a circular necrotic wound on the plantar surface of the left forefoot measuring 5 cm by 4.5 cm with no depth, with pink granular tissue and peeling skin, a darkened area along the heel, a darkened area along the left third toe nail, and another darkened area with erythema and coolness along the lateral nail and dorsal foot. The plantar wound assessment described a facility-acquired abrasion with 40% pink/red non-granulating tissue and 60% hard, adherent necrotic tissue, and noted it appeared the resident had been picking at the wound and cutting surrounding tissue. A left heel wound assessment documented a facility-acquired abrasion with 100% necrotic tissue. Interviews with staff indicated they had not previously seen the resident with scissors or nail clippers, though the wound appeared trimmed or peeled back when first observed. The failure to identify the resident’s risk factors, consistently assess his feet in accordance with policy, and implement timely preventive interventions resulted in the development of a severely infected diabetic foot ulcer requiring hospitalization and surgical incision and drainage of a deep tissue abscess and septic arthritis in the left foot.

Additional observations and interviews highlighted the resident’s mobility patterns and behaviors that were not fully addressed in preventive planning. The resident was very mobile in a wheelchair, often propelling himself with his feet rather than using his hands on the wheels, and he was sometimes able to put on his own socks and shoes. Staff reported he normally wore socks, shoes, non-skid socks, or slippers, and he had a history of picking at scabs, though this behavior was not reflected in the care plan. When the wound was discovered, the nurse practitioner noted the sock was off and the wound looked trimmed. Subsequent notes described the resident as non-compliant with wearing a protective heel boot and continuing to propel his wheelchair with the affected foot. These documented patterns, combined with incomplete foot assessments and lack of documented interventions specific to his known risk factors and behaviors, formed the basis of the cited deficiency for failing to provide appropriate treatment and care according to orders, resident preferences, and goals, and for failing to prevent the development of the wounds.