Failure to Obtain Orders and Treat Non-Pressure Foot Ulcer After Admission
Penalty
Summary
The deficiency involves the facility’s failure to obtain physician orders and provide treatment for a non-pressure skin wound on a resident’s left foot following admission. The resident was admitted in 10/2025 with diagnoses including diabetes and a non-pressure chronic ulcer on the left foot, and hospital admission orders documented an ulcer of the left second toe with skin breakdown and toe pain. On the admission Nursing Database assessment the day after admission, nursing staff recorded scabs on the resident’s second and fourth toes and the top of the left foot, and an admission MDS completed the following week indicated a non-pressure chronic ulcer on the left foot. Despite these documented findings, there were no physician orders or wound treatments in the clinical record for the left foot ulcer from admission through mid-November. A nursing note later documented that staff sent a message to the physician about the left second toe scab and that treatment was initiated at that time. In interviews, an agency LPN who completed the admission assessment could not recall whether she confirmed physician orders for the wound and stated that normal practice would be to contact the physician if there were no orders, and a regional nurse stated that staff should ensure physician orders exist for residents with skin wounds. This failure to obtain and implement physician-directed wound care for the resident’s documented non-pressure ulcer and toe scabs during the identified period constituted the cited deficiency.
We Help Long-Term Care Teams Stay Survey-Ready
We process and analyze inspection reports and plan of correction using AI to extract insights and trends so providers can improve care quality and stay ahead of compliance risks.