Failure to Coordinate Wound Care, IV Antibiotics, and Timely Surgery for Diabetic Foot Wound
Summary
The deficiency involves the facility’s failure to coordinate and provide ordered wound care, IV antibiotics, and timely surgical scheduling for a resident with a complex left foot diabetic wound and MRSA bacteremia. The resident had multiple diagnoses including infective myositis of the left foot, abscess of the tendon sheath, osteomyelitis, MRSA infection, non‑pressure chronic foot ulcer with muscle involvement, neuropathy, COPD, type 2 DM with foot ulcer, prior right great toe amputation, weight loss, hypertension, and anemia. The resident was cognitively intact per MDS and required supervision or touching assistance for most ADLs. Care plan entries noted chronic wounds/infection, risk for skin impairments related to diabetes and impaired mobility, and that the resident had a history of removing dressings and unplugging the wound vac without notifying staff. Wound notes documented progressive worsening of the left plantar foot wound from 2/10/2026 through 4/7/2026, with increasing size, presence of exudate, and visible bone. The facility did not consistently follow physician orders for wound care and IV antibiotic therapy after the resident’s hospitalization for left foot MRSA infection. Hospital discharge instructions included Daptomycin 500 mg IV every 24 hours until 4/17/2026 with weekly labs, and wound care orders from the podiatrist specified saline wet‑to‑dry dressing changes twice daily. The March MAR showed that an order to cleanse the left foot, leave the Restrada graft in place, and apply wet‑to‑dry dressings and ABD wrap when the wound vac was not available was not documented as completed from 3/13/2026 to 3/31/2026. The April MAR showed missed doses of Daptomycin on 4/8/2026, 4/9/2026, and 4/12/2026, and administration times that did not follow the every‑24‑hour order on five days. The April MAR also showed missed Hibiclens pre‑surgical dose, missed PICC/midline assessments on specified dates, and missed faxing of lab results on multiple days. The DON and ADON acknowledged that if care or medications were not documented on the MAR, they were not done, and the Medical Director stated he expected all physician orders to be followed and no doses to be missed. The facility also failed to effectively coordinate and prioritize scheduling of the resident’s needed foot surgery despite repeated contacts from the podiatrist and his clinic. The podiatrist documented on 3/31/2026 that the left foot wound was worsening, with exposed bone and need for repeat debridement and left first ray amputation, and stated he faxed orders to the facility and called multiple times without return calls. He reported calling the facility over six times, leaving messages that the resident needed surgery STAT due to exposed bone and osteomyelitis, and that no one called him back until the ADON eventually responded in April. The podiatry clinic RN reported attempts to contact the facility on multiple consecutive days to schedule surgery after insurance approval, with successful contact only after about a week. The CNA/receptionist and an LPN corroborated that the podiatrist had called repeatedly, was upset that the DON was not returning calls, and threatened to contact Public Health. Facility leadership, including the Administrator, DON, and ADON, stated they were initially unaware of issues or delays with scheduling the surgery, and staff reported that the facility had been without a wound nurse for about a month, during which time wound responsibilities were informally covered by an LPN while also working the floor. Ultimately, the resident underwent surgery and had more of the left foot amputated due to infection, with the podiatrist stating he believed more of the foot had to be removed because surgery was not scheduled earlier and that the facility had not coordinated care or returned calls in a timely manner. On physical observation shortly before surgery, the resident’s left foot showed a large plantar wound with visible bone and a red streak across the foot, with the area larger than a fifty‑cent piece. Staff interviews indicated that the wound had been present and problematic for at least a year, and that bone visibility was not noted that far back. Wound notes from late March and early April documented that the wound was advancing, increasing in size, with serosanguinous exudate and visible bone. The facility had no wound care policy, and the Administrator stated they expected physician orders to be followed. The Physician‑Family Notification policy required timely communication with the physician and family when there was a need to alter treatment significantly, and the Medication Administration policy required medications to be administered in accordance with physician orders and documented on the MAR. Despite these policies, the record review, interviews, and observations showed that the facility did not ensure consistent implementation of ordered wound care, IV antibiotic therapy, lab monitoring, PICC assessments, and timely coordination of surgical intervention for this resident’s worsening foot wound. The DON reported limited RN staffing for a census of 118 residents and stated that while they were doing the best they could, it was not enough at times. Staff also reported that the facility had been without a designated wound nurse for about a month, and that wound care duties were being informally covered by an LPN who was also assigned to floor duties. The podiatrist and his clinic staff described multiple unsuccessful attempts to reach facility leadership to arrange surgery, and internal staff accounts confirmed that calls were routed to the DON without response for a period of time. The combination of missed and improperly timed antibiotic doses, incomplete wound treatments, inconsistent lab faxing and PICC assessments, lack of a wound care policy, absence of a wound nurse for a period, and failure to respond promptly to the podiatrist’s repeated efforts to schedule surgery all contributed to a delay in surgical intervention for the resident’s left foot wound, culminating in a more extensive amputation due to the spread of infection.
Penalty
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Below are regulatory guidelines relevant to this citation:
A resident with insulin-dependent type 2 DM and mild cognitive impairment had a rapid BG drop after receiving sliding scale insulin. The resident reported fear of overnight hypoglycemia and requested BG checks every 2 hours, but the record did not show overnight monitoring, reassessment, or follow-up. Staff later stated the night nurse was notified, while the resident said BG was not checked again until breakfast.
Failure to provide ordered wound care and aspiration precautions: A resident returned from a dermatology procedure with biopsy-site dressings and the chart lacked documentation of assessment or wound care, while the dressings remained in place and undated during observations. The same resident also had dysphagia with a FEES showing silent penetration with straw sips and an order for no straws, yet was observed drinking water from a cup with a straw; the SLP and DON confirmed the no-straw precaution and expectation to follow physician orders.
Failure to Monitor Ordered Vital Signs: A resident with COPD, chronic respiratory failure with hypoxia, and CHF had a provider order for daily vital signs, but the MAR showed an O2 sat of 87% with no follow-up vitals documented and another day with no vitals documented at all. Nursing notes did not show follow-up monitoring or documentation of the low O2 reading, and the CNO stated vitals were recorded on the night shift but not entered into the record or explained when the day-shift vitals were not completed as ordered.
Medication Administered Despite Hold Parameters: A resident with HTN and hyperlipidemia had an order for midodrine with BP hold parameters, but licensed nurses administered the medication multiple times even when the resident's BP met or exceeded the ordered limits. MAR review showed doses were given despite systolic and/or diastolic readings at or above the hold threshold, and the NHA acknowledged the medication was administered contrary to the physician's parameters.
Failure to assess and report abnormal blood glucose and document change in condition: The facility did not notify the MD of abnormal CBG results or assess for hypo/hyperglycemia for two residents with DM who had insulin orders and abnormal readings, including low and high values. The record also showed inaccurate documentation for another resident with a bruise of unknown origin that was monitored briefly and then no longer documented.
A facility failed to notify the provider about a resident’s weight changes per physician order. The resident had CAD, HF, HTN, and dementia, and the record showed weight fluctuations of 4 lbs and 5 lbs, but there was no evidence the provider was updated. The DON confirmed the provider was never notified and stated the provider should have been informed per the order.
Failure to Monitor Blood Glucose After Rapid Drop
Penalty
Summary
The facility failed to provide the care and services needed to safely manage diabetes for one resident with insulin-dependent type 2 diabetes and mild cognitive impairment. The resident’s care plan directed staff to monitor for signs and symptoms of high and low blood sugar, check blood glucose as ordered, administer scheduled and sliding scale insulin as ordered, encourage bedtime diabetic snacks, and provide ongoing diabetic foot care. On 7/15/26 at 12:25 a.m., the resident had a blood glucose of 330 before dinner and received 4 units of sliding scale insulin as ordered. The resident expressed concern about receiving the full insulin dose because of fear that blood sugar would drop during the night. About one hour later, the resident’s blood glucose decreased to 97. Staff gave 15 grams of carbohydrates and one glass of juice, and the blood glucose increased to 160. The resident then requested blood glucose checks every two hours during the night because of fear that blood sugar would fall below 50, and the nurse documented that the night nurse was notified. However, the medical record did not identify blood glucose monitoring, reassessment, or follow-up during the night. During interviews, the resident stated staff did not check blood sugar until breakfast the next morning and said, "They don't like checking it." Staff and the DON stated residents’ concerns should be documented and reassurance provided when blood sugar concerns were expressed.
Failure to Provide Ordered Wound Care and Aspiration Precautions
Penalty
Summary
The facility failed to provide timely post-procedure wound care for a resident who returned from a dermatology visit after a skin growth evaluation and treatment. The resident came back with dressings covering biopsy sites on the head and face, and the dermatology visit summary instructed staff to allow the pressure dressing to remain in place for 24 hours, then remove it, clean the wound daily with mild soap and water, pat dry, apply white petrolatum, and cover with a Band-Aid until healed. During observations on two consecutive days, the resident was still seen in bed with the dressings on the biopsy sites, and the dressings were not dated. The record contained no documentation that the biopsy sites were assessed upon return from the procedure and no documentation that wound care was performed on either day. The facility also failed to follow physician-ordered aspiration precautions for a resident with dysphagia. A FEES showed silent penetration with straw sips of thin liquids, and the resident was ordered an easy-to-chew diet with no straws. The care plan also directed staff not to provide beverages with a straw. Despite this, the resident was observed drinking water from a cup containing a straw. A CNA stated, "Well how else are we supposed to give him a water cup, we have to provide water." The SLP confirmed the FEES findings and the no-straw precaution, and the Medical Director stated he expected staff to follow physician orders and aspiration precautions for residents with dysphagia.
Failure to Monitor Ordered Vital Signs
Penalty
Summary
The facility failed to monitor vital signs as ordered by the physician for Resident #46, who was admitted with multiple diagnoses including COPD with acute exacerbation, chronic respiratory failure with hypoxia, and congestive heart failure. The facility policy titled Vital Signs stated that vital signs are to be taken as ordered by the provider and documented immediately after measurement, and that abnormal or concerning vital signs must be reported to the licensed nurse for assessment and intervention. A physician order dated 5/19/26 directed that Resident #46's vital signs be taken once daily during the day shift. The June 2026 MAR documented an oxygen saturation of 87% on 6/5/26 with no follow-up vital signs documented, and no vital signs documented on 6/6/26. The resident's nursing progress notes did not document follow-up vital sign monitoring or that the oxygen saturation was below 88%. The CNO stated that there was no documentation of follow-up measures or monitoring related to the low oxygen reading on 6/5/26, and that on 6/6/26 the night shift recorded vitals but did not enter them into the medical record or document why the vitals were not taken during the day shift as ordered.
Medication Administered Despite Hold Parameters
Penalty
Summary
The facility failed to provide nursing services consistent with professional standards of quality by not ensuring licensed nurses administered medications according to physician-ordered parameters for one resident. The resident had diagnoses including hypertension and hyperlipidemia. A physician order dated June 24, 2026, directed midodrine 10 mg by mouth three times daily, with instructions to hold the medication if systolic blood pressure was greater than or equal to 120 mmHg or if diastolic blood pressure was greater than or equal to 80 mmHg. Review of the medication administration record and documented blood pressure readings showed staff administered midodrine on multiple occasions even though the resident's blood pressure met or exceeded the ordered hold parameters. The medication was given when blood pressure readings included 125/72, 125/74, 122/80, 112/80, 126/66, 122/68, 126/68, and 126/68. During an interview, the Nursing Home Administrator acknowledged that staff administered the medication despite blood pressure readings that met the physician's ordered parameters requiring the medication to be withheld.
Failure to Assess and Report Abnormal Blood Glucose and Document Resident Change in Condition
Penalty
Summary
The facility failed to notify the physician of increased and decreased capillary blood glucose (CBG) levels and failed to assess residents for hyperglycemia and hypoglycemia, as well as changes in physical assessment, for three residents. Facility policy for hypoglycemia required timely initiation of emergency treatment using approved protocols, and the general documentation policy required accurate, timely documentation of resident status, interventions, and notification of appropriate parties. The facility did not have a specific hyperglycemia policy and relied on physician orders for parameters. Resident R3 had diagnoses including hypertension, diabetes, cerebrovascular accident, and dementia. Physician orders included Lantus 30 units at bedtime and Novolog 6 units with meals, along with sliding scale insulin. The eMAR showed CBG readings of 70 and 67, and the record indicated the resident was not assessed for hyperglycemia or hypoglycemia, blood glucose was not monitored for effectiveness of treatment, care plan interventions were not followed, and the physician was not notified of the abnormal results. Resident R137 had diagnoses including hypertension, diabetes, muscle weakness, and cognitive communication deficit. Orders included checking blood sugars as needed for signs and symptoms of hypo- or hyperglycemia, rechecking blood sugars over 350 in 4 hours, fasting blood sugars every morning, post-prandial blood sugars, and Novolog 25 units with breakfast and lunch plus sliding scale coverage. The eMAR showed blood glucose values of LOW, 432, 45, and 0, and the record indicated the resident was not assessed for hyperglycemia or hypoglycemia, blood glucose was not monitored for effectiveness of treatment, care plan interventions were not followed, and the physician was not notified. Resident R11’s record showed a bruise to the left eye/brow with unknown origin, continued monitoring notes, and then no further documentation about whether the bruise resolved; the Nursing Home Administrator confirmed the facility failed to document accurately for this resident.
Failure to Notify Provider of Significant Weight Changes
Penalty
Summary
The facility failed to update the provider about resident R8’s weight changes per physician order. R8’s record showed diagnoses including coronary artery disease, heart failure, hypertension, and dementia, and the annual MDS indicated R8 was mildly cognitively impaired. A physician order dated 7-9-26 directed daily weights and to report a change of 3 lbs overnight. The weight record showed a 4 lb decrease from 153.5 lbs to 149.5 lbs and a 5 lb increase from 148.5 lbs to 153.5 lbs, but the medical record lacked evidence that the provider was ever notified of these changes. The DON confirmed by email that the provider was never updated, and later stated the provider should have been notified per the order.
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