Failure to Perform and Document Weekly Assessments of Diabetic Foot Ulcer
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to complete weekly measurements and comprehensive assessments of a resident’s diabetic ulcer as required by facility policy and the resident’s care plan. During observation, the resident was seen seated in his room while the wound care nurse removed the dressing from the bottom of his right foot, revealing a large, round, dark-colored area on the ball of the foot below the right great toe with raised edges. The wound care nurse stated the wound was a diabetic ulcer related to a bone deformity and that the resident went out to a podiatrist for wound care, but she did not have any wound notes or assessments for the resident and deferred to the ADON for the location of podiatry notes. The ADON later stated that wound documentation should be scanned into the electronic medical record and that staff should be monitoring and documenting the wound weekly using the wound observation tool, acknowledging that the lack of documentation was likely a mistake. Record review showed that weekly skin assessments over several months documented that the resident was being followed by a physician for a diabetic wound to the right plantar foot and that a treatment order was in place, but these assessments did not include measurements or descriptions of the wound. The podiatrist’s note, which the ADON produced, documented a full-thickness diabetic neuropathic ulcer on the bottom of the resident’s right foot, with specific post-debridement measurements, confirming the presence and severity of the wound. The resident’s diagnoses included type 2 DM with foot ulcer and vascular dementia, and physician orders directed daily betadine application and use of a post-op shoe. The resident’s care plan and the facility’s wound treatment management policy required monitoring and documentation of wound location, size, and characteristics, including measurements and detailed assessment, but the facility’s own documentation lacked these required elements for this resident’s diabetic ulcer.
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