Failure to Notify Provider and Representative of Change in Condition and Refusal of Podiatry Care
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician and resident representative of a change in condition and refusal of care for one resident reviewed for allegations of neglect. The resident had diagnoses including mild cognitive impairment, dysthymic disorder, left foot drop, moderate protein calorie malnutrition, PVD, neuropathy, onychomycosis, and dermatophytosis. A quarterly MDS showed intact cognition with dependence on staff for personal hygiene, bed mobility, and transfers. A podiatry note documented that all ten toenails were thick, yellow, brittle, with subungual debris, and that aseptic debridement was performed with a plan for follow-up in 6–8 weeks. However, from the date of that podiatry visit through early the following year, the clinical record did not show that the provider or the resident’s conservator had been notified of the toenail condition or the need for follow-up. Subsequent podiatry service lists over several months identified that the resident was due for follow-up for tinea unguium, but visits were repeatedly rescheduled without documented reasons, and the resident was not seen. A later podiatry service list showed that the resident refused a scheduled podiatry visit. Nursing notes for the days following this refusal did not contain documentation of the refusal, any assessment of the refusal, or notification to the provider or the resident’s conservator. A facility reportable event later documented receipt of a complaint alleging neglect due to the appearance of the resident’s legs and stated that the resident had been seen by podiatry and wound personnel but refused treatments and had since been discharged. The resident’s conservator reported being present at the admission assessment at the receiving facility and observed that the resident’s toenails were so thick and long they were curling, and stated shock at their condition. The conservator stated that the facility had never notified them of podiatry issues or refusals of treatment and that they would have advocated for care if informed. The DON and APRN both stated they had not been notified of the condition of the toenails or the refusal of podiatry care and indicated that nursing staff should have documented the podiatry visit, ongoing toenail condition, and refusal, and notified the provider and conservator. Facility policies on notification of change in condition, refusal of treatment, and foot care required timely notification of the physician and healthcare decision maker, assessment and documentation of refusals, and appropriate referral and follow-up for residents with complicating disease processes requiring foot care, which were not followed in this case.
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