Failure to Care Plan Left Foot Drop and Podiatry Conditions
Penalty
Summary
The facility failed to develop an individualized, comprehensive care plan to address a resident’s left foot drop, which was documented in hospital records as a past medical history diagnosis at the time of admission in 2022. Review of the resident care plan from admission through early February 2026 showed no identification of left foot drop and no interventions to treat or manage this condition. A physical therapist reported that the resident was admitted with significant left foot drop and that therapy attempted to use an AFO brace, but the resident refused, leading to discontinuation. The therapist stated that therapy reattempted AFO use and therapy services several times, but the resident refused to participate or get out of bed. The therapist also indicated that therapy communicated functional and ADL status updates to nursing, and that nursing was responsible for developing the resident care plan with appropriate interventions, including care planning for left foot drop and documenting refusals since admission. The facility also failed to care plan podiatry abnormalities identified during the resident’s stay. A podiatry note documented that the resident had thick, yellow, brittle toenails with subungual debris and diagnoses of PVD, neuropathy, onychomycosis, and dermatophytosis, and that aseptic debridement of all ten elongated, thick toenails was performed with a plan for follow-up. However, review of the resident care plan from the date of this podiatry visit through early February 2026 showed no care plan addressing nail disorders, infections, or foot and nail diagnoses to ensure proper treatment and prevent complications. The DON stated that the IDT should have care planned the left foot drop present on admission, initiated interventions, documented treatment refusals, and that licensed nursing staff or the IDT reviewing podiatry notes should have developed a podiatry care plan with interventions. The facility’s Person-Centered Care Plan policy required comprehensive, individualized care plans with measurable objectives and timetables, including services not provided due to the resident’s right to refuse treatment, to be developed and reviewed based on comprehensive assessments.
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