F0710

E

Failure to Ensure Provider Assessment and Care Planning for New Diabetic Foot Ulcer

Mt. Pleasant, Michigan Survey Completed on 02-11-2026

Penalty

No penalty information released

Summary

Surveyors identified a failure to ensure adequate medical provider supervision for a resident with diabetes mellitus who was admitted to the facility on 12/10/2024. The electronic medical record showed that on 1/13/2026 nursing staff documented a new in-house acquired diabetic foot ulcer on the left lateral mid-foot, including measurements and dressing, but there was no documentation that the medical provider was notified of the new wound or its characteristics. A new physician order for treatment of a left foot pressure injury with betadine and white border gauze in the morning was entered with a start date of 1/14/2026, but the record did not show that the medical provider physically assessed the wound.

Progress notes documented medical provider encounters with the resident on 1/16/2026, 1/21/2026, and 2/3/2026, during which constipation and left thumb pain were addressed, but there was no documentation of a physical assessment or acknowledgment of the left foot wound during these visits. The care plan revealed that a nursing care plan for the new wound, first identified on 1/13/2026, was not formulated until after the survey began on 2/9/2026, indicating that prior to that time the medical provider and nursing staff had not collaborated to develop a comprehensive care plan for the wound. During interview, the unit manager stated that mid-level providers review wound photographs but acknowledged there was no documentation that any provider had reviewed photos or evaluated the wound, and no additional documentation was provided by survey exit on 2/10/2026.