Failure to Accurately Document Wound Care and Update Care Plan for Diabetic Foot Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to maintain clear, complete, and accurate documentation in the EMR and to update the care plan for a cognitively intact resident with diabetes mellitus who was admitted on 12/10/2024. A new diabetic foot ulcer on the left lateral mid-foot was identified and documented on 1/13/2026 as an in-house acquired wound that was measured and dressed. A treatment order was entered on the TAR starting 1/14/2026 for a left foot pressure injury to be treated with betadine and white border gauze each morning. Review of the TAR for January and February 2026 showed that nursing staff did not initial the treatment as completed on 11 of 27 days after the treatment was ordered, and there were no nursing progress notes explaining why the treatments were not performed, delayed, or refused, nor any documentation that the medical provider was notified of any interruption or rejection of care. The resident’s care plan was not revised to include the new wound identified on 1/13/2026 until after the survey began on 2/9/2026, indicating that prior to that date the care plan had not been updated to address the wound. Interviews with the UM and DON confirmed that the resident often dictated when and by whom care was provided and that they assumed refusals or delays in treatment, but they acknowledged that the medical record lacked documentation of refusals, delays, completion of treatments, provider notification, or resident education regarding delayed or refused care. Job descriptions for RNs and LPNs provided by the facility required accurate and prompt implementation of physician orders, assessment and documentation of resident condition and nursing needs, and documentation of treatments as required by company policy and applicable regulations, but as of survey exit no additional information was provided to clarify the nursing care or documentation for this resident.
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