F0684

D

Failure to Timely Assess and Notify Physician of Foot Wound

Murrieta, California Survey Completed on 03-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to ensure that a resident’s left great toe skin condition was promptly evaluated and referred to a physician after it was first identified. On February 10, 2026, a CNA reported that while assisting the resident in bed, the resident complained of foot pain. Upon removing the sock, the CNA observed a blister on the left great toe with slightly lifted skin and pink tissue underneath, without bleeding or drainage. The CNA stated she notified the Treatment Nurse, who replied she was doing rounds anyway, but when the CNA returned to work two days later, she had received no report or update that anything had been done about the blister.

The resident’s medical record showed she had been admitted with diagnoses including diabetes mellitus, morbid obesity, and dementia, and her MDS indicated memory problems and cognitive difficulty in new situations. The record contained a physician’s order dated February 14, 2026, to send the resident to the ER for evaluation of the left foot due to green and red discoloration, a skin tear, and buildup of skin debris, and an eINTERACT Change in Condition Evaluation documented a change in condition related to a skin wound or ulcer, with lack of treatment noted as a factor keeping the condition unchanged. The narrative in that evaluation described the family approaching the nursing station about skin concerns to the left foot, and staff then observing green and red discoloration to the left great toe and top of the left foot, a skin tear, and skin debris buildup. There was no indication in the record that the wound on the left great toe was assessed and referred to the physician when first identified by the CNA on February 10, 2026, and no care plan was developed to address the left foot wound.

Further interviews supported that the skin condition was present and unaddressed before the physician was notified. A second CNA confirmed assisting with repositioning the resident in early February, hearing the resident complain of left foot pain, and seeing that the sock was removed, revealing a dry, flaky wound that was not yet open; she stated CNA 1 said she would notify the Treatment Nurse and left the sock off because it was hurting the foot. An LVN later reported that in the evening of February 14, 2026, a family member was upset about the foot wound, and the LVN then observed three areas of excess green skin debris, flaky skin on the top of the foot, a concerning toenail with a reddened nail bed, a lateral foot area that looked like a wound with a blackened area, and extension of the condition between the great and second toes. The LVN stated there had been no prior communication or documentation about the skin condition in the chart before that time. Facility policies required examination and assessment of skin, notification of the physician of abnormalities such as wounds or rashes, and prompt notification of the physician and resident representative of changes in condition, but the documentation and interviews showed these steps were not carried out when the skin issue was first identified.