Failure to Assess and Document Care for Resident With Frostbitten Feet
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals by not adequately assessing, monitoring, or documenting the condition of a resident’s frost-bitten feet. The resident was admitted with diagnoses including pain in both feet and frostbite of the feet, and the admission evaluation documented frostbite to both feet under the integumentary section. The resident’s BIMS score indicated intact cognition. A family member reported that the resident was admitted with bandages on both feet and that during a visit the day after admission, nursing staff were reminded that the bandages had not been changed. On the following morning, the family member again found both feet still wrapped in the original hospital bandages, which had a bad stench, and after staff did not respond in a timely manner, emergency services were called and the resident was transported to the hospital. Record review showed there were no physician orders to assess, monitor, or provide care for the resident’s bilateral feet, and no documentation in progress notes from admission through the date of transfer describing the feet, assessing them, or monitoring them. Medication and treatment administration records contained no related physician orders, and skilled nursing notes either omitted any assessment of the feet or only noted that dressings were present, without further description. The resident’s skin care plan contained no interventions for monitoring, assessment, or treatment of the feet. The DON stated that the resident had no dressings applied at admission, that the feet should have been assessed and monitored regardless of any bandage, and later acknowledged that nursing staff should have thoroughly examined and documented the bandages and notified the physician so that treatment orders could be obtained. Facility policy required that skin alterations be evaluated and documented by a licensed nurse using the admission or readmission evaluation.
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