F0687

D

Failure to Follow Physician Orders for Toe Wound Care

Kennedale, Texas Survey Completed on 02-19-2026

Penalty

No penalty information released

Summary

The facility failed to provide proper foot care and follow physician orders for wound care for one resident with a left great toe wound. The resident was an older female with a history of stroke affecting the left side, pressure ulcers, morbid obesity, skin concerns related to mobility issues, and an ADL self-care deficit. A physician’s order dated 02/09/26 directed that Mupirocin 2% ointment be applied to the left great toe twice daily after cleansing with antimicrobial solution and then covering with a dry dressing or bandage. The February 2026 Treatment Administration Record showed no documentation that this wound care was provided twice daily on multiple dates, specifically the 11th, 12th, 13th, 14th, 16th, and 18th.

On 02/19/26, surveyors observed that the resident’s left great toe dressing was dated 2/18 and remained unchanged through several observations that day. The treatment nurse stated she handled major wounds while bedside nurses handled minor wounds and believed this resident’s wound care was ordered once daily; she could not explain why the wound care had not been done on 02/19/26. Upon removing the dressing, the treatment nurse observed the toenail was missing with a pink, healthy nailbed and no signs of infection. An LVN working the 6:00 AM–2:00 PM shift stated she normally did wound care at the end of her shift, had not provided this resident’s wound care that day, and was unaware the order was for twice-daily treatment. The regional nurse consultant stated staff followed physician orders for wound care and that the risk of not following the physician’s order was that the physician would be upset. The facility’s wound care policy required verification of the physician’s order and documentation of the date and initials of the person performing wound care.