Missed Antibiotic Doses and Unperformed Wound Treatments for Resident With Diabetic Foot Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered wound care treatments and prescribed antibiotics for a resident with multiple diabetic foot ulcers and recent right great toe amputation. The resident, who had Alzheimer’s disease, peripheral vascular disease, and documented memory problems, was readmitted after hospitalization for sepsis and osteomyelitis, during which the right great toe and associated structures were amputated and a right heel wound was debrided and treated with a wound vac. Infectious Disease ordered a six-week course of Doxycycline and Augmentin. Physician orders specified Doxycycline 100 mg orally twice daily for a wound infection, but the MAR showed multiple missed doses on several mornings and one evening with no evidence of administration. The resident had numerous documented wounds, including a right second toe diabetic ulcer with necrotic eschar, a right plantar foot diabetic wound with depth and tunneling, a right fourth lateral toe web ulcer with granulation tissue, a right fourth toe tip ulcer with eschar, a right great toe amputation site with granulation tissue, and a left plantar foot diabetic ulcer. Physician orders detailed specific wound care regimens for each site, including cleansing with normal saline, patting dry, applying calcium alginate, mesalt rope packing, oil emulsion, betadine, and appropriate dressings such as abdominal pads and kerlix, to be completed daily and as needed until resolved or healed. These orders were updated over time to reflect changes in wound status and treatment approach, including packing of the right plantar wound tunneling and shift-based care for the left medial plantar foot. Review of the treatment administration records revealed no evidence that ordered wound care was completed on multiple dates for the right second through fifth toes, the right plantar foot incision, the right fourth lateral toe, the right great toe amputation site, and the left medial foot. The wound nurse confirmed during interview that the resident’s diabetic foot ulcers began as a closed callus and became necrotic within two days, leading to hospitalization for osteomyelitis and amputation, and also confirmed she was unaware that multiple doses of Doxycycline had not been administered and that the medical record lacked documentation of wound care for multiple wounds. The wound NP reported the resident had multiple incisions and gangrenous toes, self-propelled and hit his feet on objects on the secured memory care unit, and had poor nutrition, but denied concern with the wound care. The facility’s wound care policy stated its purpose was to provide guidelines for wound care to promote healing, yet the record review showed missing antibiotic administrations and undocumented wound treatments contrary to physician orders.
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