Failure to Resume and Act on Podiatry Order for Diabetic Resident
Penalty
Summary
The facility failed to provide podiatry care for a resident with diabetes, hemiplegia, and hemiparesis, who was dependent on staff for ADLs but had intact cognition for daily decision making. The resident had a physician’s order for a podiatry consult and treatment as needed, originally dated 11/2/25. After the resident was hospitalized, all physician orders were placed on hold. When the resident returned from the hospital, staff resumed all orders except the podiatry consult, which remained on hold and was not active. The resident reported that a staff member had recently indicated they would make a podiatry appointment, but the resident had not received any update on the status of that appointment. Nursing staff were aware of the resident’s foot condition but did not act on it. An LVN stated they observed the resident’s long and thickened toenails on 11/20/25 when completing a Change of Condition report for heel redness, but they did not complete a change of condition report related to the toenails and did not notify the physician about this issue. The LVN also stated that, because the resident was diabetic and at high risk for infection, facility staff generally would not trim the resident’s toenails. On observation, the resident’s toenails on both feet were noted to be long and thickened. Facility policies on resident rights and change in condition required that residents be informed of and participate in their care and that physicians be notified of significant changes in condition, but these processes were not followed for the resident’s podiatry needs.
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