F0684

D

Failure to Assess and Monitor Non-Pressure Toe Wound Leading to Infection and Amputation

Salisbury, Maryland Survey Completed on 03-20-2026

Penalty

No penalty information released

Summary

The facility failed to provide updated non-pressure wound assessments and failed to identify and monitor a new wound on a resident’s left great toe, resulting in delayed treatment for an infected wound. The resident had multiple diagnoses including morbid obesity, Type II diabetes, Stage 5 chronic kidney disease, stroke with left-sided weakness, and dementia, and had a physician order for weekly skin assessments to be documented every Monday. On 12/30/2025, a staff member alerted the unit manager LPN to a 0.5 cm open area under the resident’s left great toenail; the LPN observed the wound, documented the change in condition, and notified the physician and family. The physician ordered lab work, a venous doppler, and dressing care with betadine wet-to-dry dressings every shift. An assessment form completed that morning triggered a skin change in condition and indicated that a Braden Observation tool, Pain Observation tool, and Skin Grid (Pressure and Non-Pressure) tool should be completed and placed in the record, but there was no evidence that any of these three assessment tools were completed.

Subsequent documentation failed to reflect ongoing assessment or monitoring of the left great toe wound. The doppler results reported on 12/31/2025 showed mild peripheral vascular disease in the left lower extremity without occlusion. However, review of the January Weekly Skin Integrity Reviews revealed no mention of the left great toe wound’s status, including any measurements or descriptions, for several weeks. On 01/05/2026, an LPN documented there were no skin areas; on 01/12/2026, another LPN documented there were no skin areas since the last skin check; and on 01/19/2026, an RN documented there was a skin area but did not attach an assessment of the left great toe. During this period, the resident’s care plan, which had previously identified risk for skin integrity issues, was not updated and no new care plan was initiated related to the non-pressure wound of the left great toe first identified on 12/30/2025.

On 01/26/2026, an RN documented that the resident’s left great toe was swollen, red, warm, and tender, with the toenail no longer attached and the surrounding skin off, and areas of dark discoloration around the left toes. The RN notified the skin and wound consultant CRNP, who assessed the wound the same day. The CRNP documented that neither the resident nor facility nursing staff knew when the left great toe wound first appeared or what caused it, and described the toe as having the toenail removed with a large sheet of skin peeled off the entire distal toe. The CRNP’s wound assessment identified cellulitis and a new full-thickness wound measuring 2.1 cm x 6 cm x 0.3 cm with exposed dermis and subcutaneous tissue, unattached wound edges, and moderate serosanguineous drainage, though the resident denied pain. The CRNP cleansed and dressed the wound in preparation for transfer to the hospital, where the resident was later admitted for MRSA bacteremia secondary to a left foot wound and ultimately underwent a left below-knee amputation.