F0842

D

Failure to Document NP/MD Notification of Osteomyelitis Diagnosis

El Paso, Texas Survey Completed on 02-03-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain a complete and accurately documented medical record for a resident with a diagnosis of osteomyelitis. The resident, an older male with diabetes mellitus with hyperglycemia and open wounds of the left foot and great toe, had been admitted to the facility in February 2025 and discharged in January 2026. Hospital records from February 2025 documented concern for and MRI-confirmed calcaneal osteomyelitis of the left foot and possible osteomyelitis of the left 5th toe, with a plan for antibiotic therapy. The resident’s discharge MDS showed moderately impaired cognitive skills for daily decision-making, indicating the resident required cues or supervision.

On December 9, 2025, a facility progress note documented that the resident had a podiatry appointment. A podiatrist’s progress note (undated in the record) later indicated erosion of the left 5th toe consistent with osteomyelitis and stated that infectious disease would be consulted that day, noting the toe was stable. However, the facility’s progress notes dated December 10, 2025 contained no documentation of the podiatrist’s osteomyelitis diagnosis and no record that the NP/MD was notified of this diagnosis. A subsequent progress note dated December 12, 2025 documented that the resident was sent to the hospital for further evaluation of osteomyelitis because the VA infectious disease appointment was taking too long to schedule.

Interviews with staff confirmed that facility practice and expectations required nurses to review outside provider notes, notify the NP/MD immediately of any new orders or diagnoses, and document this notification in a progress note. LVN A stated that the nurse receiving the resident from an outside appointment and whoever reviewed the progress note were responsible for informing the NP and documenting the notification, and that failure to do so could result in delay in care and miscommunication. LVN B reported he was not aware of the osteomyelitis diagnosis until informed by the resident’s POA on December 12, 2025 and acknowledged that nurses were expected to notify the NP immediately of changes and document this, though he did not always document a note if there were no new orders. The DON stated that, in this case, she did not believe immediate NP notification was necessary because the podiatrist’s note contained no new orders and described the condition as stable, and she considered next-day notification acceptable. The Administrator, however, stated that staff were to notify the nursing supervisor and NP immediately of any new orders or changes in diagnosis and document a progress note. Review of the facility’s October 2021 “Medical Record Documentation” policy showed that licensed staff and interdisciplinary team members were required to document observations and services provided in the resident’s medical record in accordance with state law. The absence of documentation of NP/MD notification of the osteomyelitis diagnosis on December 10, 2025 constituted the cited deficiency.