F0687

D

Failure to Ensure Timely Diabetic Footwear and Foot Care Follow-Up

Overland Park, Kansas Survey Completed on 02-02-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide necessary foot care and services for a resident with diabetes and mobility issues, specifically related to obtaining diabetic shoes. The resident had diagnoses including right knee pain, cognitive communication deficit, difficulty walking, and diabetes mellitus, with MDS assessments showing moderate cognitive impairment. The care plan identified actual risk for ADL/mobility decline and documented the need for staff assistance with ambulation and transfers, as well as encouragement of activity and exercise. A podiatry order form documented an order for diabetic shoes and heat-molded insoles, and nursing notes showed that staff attempted to contact the diabetic shoe provider multiple times over several days, faxing requested documents and leaving voicemails.

After the last documented contact with the shoe provider, the EMR contained no further evidence of follow-up by the facility, despite the resident later stating she still needed diabetic shoes. Observation showed the resident seated or lying in her room, with a rough, calloused appearance on the right heel. A licensed nurse reported the facility had been working on obtaining the shoes for a year and a half and that the provider had not responded. An administrative nurse stated she expected weekly follow-up by nursing staff and acknowledged that the resident should at least have had an appointment date by that time. She later learned the resident had missed a prior appointment with the shoe provider and had not wanted to reschedule during a period of psychosis and involuntary placement, and that the provider had no record of further referrals beyond that missed appointment. The facility did not provide a policy on durable medical equipment or accommodation of needs.