Failure to Provide Diabetic Shoes Leads to Amputation
Summary
The facility failed to ensure a resident with a history of bilateral foot diabetic ulcers received diabetic shoes as ordered by the physician. The order for diabetic shoes was placed on 7/10/24, but the facility did not follow up with the shoe vendor to ensure the shoes were ordered and delivered. This oversight continued throughout July, and by 8/30/24, the resident developed a foot ulcer, indicating a lack of preventative foot care measures. The resident, who had a history of Type 2 diabetes with foot ulcers and neuropathy, expressed a desire for diabetic shoes on 8/26/24. Despite this, the facility did not document any communication or follow-up with the shoe vendor between 7/10/24 and 8/30/24. The resident's condition worsened, leading to a wound on the left heel, which eventually required debridement and resulted in a left foot amputation on 10/26/24 and a below-the-knee amputation on 10/31/24. Interviews with facility staff and the shoe vendor revealed that the vendor requested additional paperwork to fulfill the shoe order, but the facility continued to send the same paperwork without addressing the vendor's request. The Director of Nursing stated that follow-up should occur within 24-48 hours, yet there was no evidence of such follow-up. The lack of timely action and communication contributed to the resident's deteriorating condition and subsequent amputations.
Removal Plan
- The DON and designee(s) conducted a full-house audit on diabetic residents to determine at-risk diabetics and ensure proper preventative foot care.
- An audit was conducted to ensure all treatments, supplies, and equipment were readily available for order by the physician and were being followed to ensure residents received the proper preventative foot care.
- DON or designee(s) reviewed the medical records of diabetic residents to ensure that weekly skin assessments were completed and treatment recommendations/orders were in place.
- The DON or designee conducted a care plan audit to ensure that treatment recommendations/orders were included in the care plan and that they were being followed.
- All facility policies and procedures related to podiatry services, skin integrity foot care, and physician orders reviewed and revised as needed.
- Education provided to regional Clinical Manager at Curana to ensure that all practitioners that come to Pine Acres will be collaborating with the IDT team to ensure referrals are made timely and appropriately.
- An audit of orders, interventions, and devices regarding foot care and foot services was conducted by the Nursing Supervisor(s) to ensure proper use.
- The DON/Corporate Nurse/Consultant educated all licensed nurses on facility policies and procedures related to diabetes, foot care, and appropriate wound treatment measures.
- The DON/Corporate Nurse/Consultant educated all licensed nurses on appropriate documentation, which included transcription and entering treatment orders on the physician's order sheet in the EHR and the resident's TAR.
- DON/Corporate Nurse/Consultant educated all nurse aides on preventative diabetic foot care.
- DON/Corporate Nurse/Consultant conducted daily treatment record and nursing documentation audits to ensure accurate and complete documentation of diabetic foot care and preventative measures.
- For residents returning from the hospital, treatment recommendations/orders and wound care appointments will be transcribed and overseen by the DON and Corporate Nurse.
- DON/Corporate Nurse/Consultant Monitoring will continue to monitor/audit the following: Observation of treatments for diabetic foot care prevention and orders, Weekly physician orders, Weekly diabetic skin treatment orders related to diabetics, Treatment recommendations and orders are being added and processed into the EHR and TAR.
- A QAPI PIP has been initiated to report on the above monitoring and auditing procedures. All findings from the PIP will be presented at the monthly QAA meeting. Monitoring/auditing and reporting will continue.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Two residents with diabetes and significant functional impairments did not receive timely podiatry services for toenail trimming despite clear clinical indications, hospital discharge instructions, and facility policies requiring ancillary needs to be identified at admission and through ongoing assessments. One resident reported repeatedly requesting podiatry care after being told at admission that the facility would arrange it, yet no podiatry visits, consents, or refusals were documented, and later observation showed multiple overgrown toenails. Another resident, fully dependent for ADLs and at risk for skin breakdown, had weekly body audits documented and staff who noticed long toenails and believed or reported that the resident would be added to the podiatry list, but the resident was not enrolled in podiatry for many months. Surveyor observations documented markedly overgrown, thickened, and discolored toenails, while the contracted provider confirmed that simple enrollment steps were not completed in a timely manner, resulting in missed podiatry care despite multiple provider visits to the facility.
A resident with diabetes, peripheral vascular disease, dementia, and a history of diabetic ulcers was care planned for skin integrity risks and had orders for weekly skin observations and heel off-loading. A scheduled weekly skin assessment was not completed, and the next day an LPN documented a new wound on the left great toe and heel but did not record measurements or a detailed description until a week later, when the ulcers were measured and noted to contain significant eschar. Despite orders for heel boots and later heel elevation, surveyors repeatedly observed the resident in bed with feet resting on the mattress, without pressure-relief boots, heel elevation, or a linen tent, and CNAs reported never seeing such devices in use. A later dressing change revealed yellow/green drainage from the toe wound. These omissions in timely assessment, documentation, and implementation of ordered off-loading measures resulted in a deficiency for inadequate diabetic foot care.
Failure to Provide Toenail Care: A resident with dementia, anxiety, and heart failure had severely overgrown toenails, including both great toenails extending about an inch past the toe and curving to the side. The resident said she had repeatedly asked staff to trim them or arrange podiatry, but no follow-up occurred. Interviews showed nursing and social services staff were aware of the issue and that the resident needed podiatry, while the facility policy stated routine foot and toenail care should be provided within staff scope of practice.
A dependent, cognitively impaired resident with multiple comorbidities required assistance with ADLs and personal hygiene, including foot care. Over several bathing episodes, a CNA documented that the resident’s toenails were long, thick, and in need of podiatry services, and the primary nurse signed these shower sheets but did not arrange a podiatry consult or add the resident to the podiatry list. The resident was never scheduled for or seen in the facility’s podiatry clinic, and there were no EMR entries indicating podiatry involvement. When later observed by surveyors and unit managers, the resident’s toenails on both feet were found to be thick, long, and curved past the nail bed, and facility leadership acknowledged they had not been aware of the condition and that nursing staff were expected to act on CNA reports of podiatry needs.
Failure to Provide Toenail Care: A resident with dementia, muscle wasting, HTN, and HF had toenails observed to be overgrown, including big toenails curving to the side. The resident said she could no longer bend over to trim them and no one had asked to do so or arrange podiatry. Staff gave conflicting accounts about who was responsible for nail care, and the SW said podiatry consent was still pending.
A resident with peripheral artery disease and chronic wounds on the left fourth and fifth toes experienced a delay in scheduling a vascular specialist visit after an NP ordered a referral based on abnormal arterial Doppler results. Facility documentation showed no referral activity for several weeks, and the vascular office later confirmed receiving the referral much later than ordered. During this time, the resident’s foot condition worsened, with an open, draining wound on the fourth toe and later CT evidence of osteomyelitis that was not promptly communicated to the wound care NP or treated with antibiotics by the primary NP. The resident’s family reported ongoing concerns about a blackened, non-healing foot wound and lack of antibiotics, and hospital records documented that the resident arrived without prior vascular evaluation or antibiotic therapy, was started on IV antibiotics, diagnosed with acute osteomyelitis and cellulitis, and ultimately required toe amputation.
Failure to Provide Timely Podiatry and Toenail Care for Diabetic Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate podiatry services, specifically toenail trimming, for two residents with diabetes and other comorbidities, despite clear indications and internal processes that should have triggered such care. For one resident with type II diabetes, polyneuropathy, and atrophic skin disorder, hospital discharge paperwork directed follow-up with a podiatrist within 1–2 weeks of discharge. Admission documentation and care plans identified functional limitations and the need for staff assistance with ADLs, but the clinical record contained no evidence that podiatry visits were scheduled, completed, canceled, or refused. The resident reported having requested podiatry services for nail trimming and stated that, at admission, the facility had indicated it would arrange these services. The ADNS acknowledged that no appointment was made following admission and that the resident was never enrolled in the contracted podiatry service, nor was there documentation of declined services. Direct observation of this resident’s feet with the DNS and Infection Preventionist showed multiple toenails on both feet extending beyond the tips of the toes, with specific measurements recorded for each toenail. The DNS stated that, due to the resident’s diabetic status, the resident should have been seen by podiatry and followed approximately every 60 days for toenail care, and that by the time of survey the resident should have already had a second podiatry visit since admission. The facility’s Ancillary Services policy states that ancillary needs, including podiatry, are to be determined at admission and through ongoing assessments, and that services will be provided by the facility or coordinated with external providers, with residents informed of available services and assisted in scheduling appointments. Despite these policy requirements and the hospital’s explicit referral instructions, the facility did not ensure that this resident received podiatry services. For a second resident with cerebral infarction, type 2 diabetes mellitus, cognitive communication deficit, muscle weakness, severe cognitive impairment, and total dependence on staff for ADLs including footwear, the facility also failed to ensure podiatry care. The care plan identified diabetes and risk for skin breakdown, with interventions to monitor extremities and inspect skin during care. Physician orders included consults for podiatry and weekly body audits on shower days. Nursing admission assessment and subsequent clinical records did not document any toenail concerns, and there was no record of podiatry visits, refusals, or offers of service from admission onward. Nursing assistants and an LPN reported having noticed and/or been told about the need for toenail trimming and believed or reported that the resident would be placed on the podiatry list, but there was no timely follow-through. The ADNS later reported that the resident was only added to the podiatry list months after admission, and the DNS stated she had not been aware earlier that the resident needed podiatry services. Observations of this second resident’s feet showed markedly overgrown and thickened toenails on both feet, with detailed measurements documenting nails extending several centimeters beyond the tips of the toes, curving under or toward adjacent toes, and dark discoloration and a dark line on certain nails. The facility’s own weekly body audits, documented as completed on the TAR, did not result in any recorded notes about toenail issues over many months. Staff interviews revealed that some nursing staff were aware of the toenail condition but either assumed the resident was already on the podiatry list or could not recall whether they had reported the issue to supervisors. The contracted ancillary services provider explained that enrollment in podiatry required only a face sheet and a completed physician order form, and confirmed that the resident was not enrolled until well after admission, despite multiple podiatry visits to the facility during the review period. The facility’s Ancillary Services policy again contrasted with these findings, as it required evaluation of ancillary needs at admission and through ongoing assessments, which did not result in timely podiatry services for this resident.
Failure to Provide Timely Assessment and Preventive Care for Diabetic Foot Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assessment and preventive interventions for a diabetic foot ulcer in a resident with multiple risk factors. The resident had Type II diabetes mellitus, a history of diabetic ulcers, peripheral vascular disease, dementia, and impaired mobility, and was care planned for potential skin integrity impairment and an existing diabetic foot ulcer. The care plan and physician orders included weekly skin observations on day shift every Wednesday, encouragement and assistance with off-loading heels, turning and repositioning, use of a low air loss mattress, monitoring and documenting skin injuries, and referral to a podiatrist or foot care nurse. A skin risk assessment identified the resident as at risk for skin breakdown due to age and dementia. Despite these identified risks and interventions, the weekly skin observation scheduled for a Wednesday in late February was not completed, and there was no documentation of that required assessment. On the following day, a change in condition evaluation documented that the resident had developed a new skin wound or ulcer to the left great toe and second toe, described as a new onset grade two or higher pressure ulcer/injury or progression of an ulcer despite interventions, with a black scab on the great toe and a scarred heel. A wound/scab was also noted on the left heel. At that time, no wound measurements or detailed description of the toe wound were documented, and the only recorded intervention was an order to apply betadine every shift and obtain bilateral arterial Doppler studies. The DON and ADON later confirmed that no description or measurements of the wound were obtained until a week later, when a skin condition evaluation documented an in-house acquired diabetic foot ulcer on the left great toe measuring 5 cm by 4 cm with undetermined depth and mostly eschar, and a second diabetic foot ulcer on the left heel measuring 1 cm by 1 cm with undetermined depth. Subsequent documentation and observations showed that preventive off-loading interventions were not consistently implemented. Although there were physician orders to encourage off-loading heel boots/protectors every shift and later to elevate/float heels when resting in bed, surveyor observations on multiple occasions found the resident in bed with socks on, feet resting directly on the mattress, without pressure relief boots, heel elevation, or a tent to keep bed linens off the lower extremities. CNAs interviewed confirmed that the resident did not have heel elevation or pressure relief boots in place when in bed and that such boots had not been observed. Later observation of the left great toe dressing revealed it had not been changed since the prior day and showed a moderate amount of yellow/green drainage when removed. The facility’s own wound management policy stated that residents with impaired skin integrity would be recognized and treated timely, with systems in place for early identification and monitoring of new skin impairments, but the documented lapses in weekly skin assessment, initial wound measurement and description, and consistent implementation of off-loading interventions led to the cited deficiency.
Failure to Provide Toenail Care
Penalty
Summary
The facility failed to ensure proper foot care and treatment for one resident, including trimming of toenails, in accordance with professional standards of practice. Resident #83 was a female with diagnoses including non-Alzheimer's dementia, anxiety disorder, and heart failure, and her BIMS score indicated severe cognitive impairment. Her MDS also showed she required substantial to maximal assistance from staff for personal hygiene, and she did not have diabetes. During observation, Resident #83 stated her only concern was her toenails. Both big toenails were observed to be approximately an inch past the tip of the toe and curved to the side, and the other toenails were approximately a quarter of an inch past the tip of the toe. Resident #83 stated she had been asking staff to trim them or to have podiatry come because she did not like seeing them that long. She stated nurses told her they were not able to cut them and that she needed to be seen by podiatry, but no one followed up with her regarding podiatry. Interviews showed CNA B, LVN A, the Social Worker, the ADON, and the DON were aware of the long toenails or the need for podiatry referral. CNA B stated nurses were responsible for trimming residents' fingernails and toenails. LVN A stated she had received report about the resident wanting her toenails trimmed and that the nails were too thick for staff to trim, and she said the resident needed a podiatry referral. The Social Worker stated the resident had last been seen by podiatry about 6 months earlier and that she was not sure why the resident was not being seen by the new podiatrist. The facility's 24 Hour Report/Changes of Condition Report noted the resident needed a podiatry consult/appointment, and the facility policy stated residents would be provided routine foot and toenail care within the professional scope of practice.
Failure to Arrange Podiatry Services and Provide Foot Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate foot care and arrange podiatry services for a dependent resident whose toenails were long, thick, and curved. The resident was admitted with hypertension, dementia, age-related physical debility, and a need for assistance with personal care, and was care planned for an ADL self-care deficit requiring staff assistance with grooming and hygiene. An admission MDS documented that the resident was severely cognitively impaired and required substantial to maximal assistance with personal hygiene and bathing, and she was not coded for rejection of care. Multiple bath/shower sheets completed by a nurse aide on three separate dates documented that the resident needed podiatry services, and these sheets were signed off by the primary nurse. Despite these repeated notations, the resident was not placed on the podiatry clinic schedule and there were no consultation reports or EMR entries indicating that podiatry services had been scheduled or provided since admission. The nurse aide reported that she had noticed the resident’s long, thick toenails from admission, had unsuccessfully attempted to trim them, and had both documented the need for podiatry and verbally informed the primary nurse on more than one occasion. The primary nurse later stated she did not recall being informed, acknowledged she had not noticed the podiatry needs on the shower sheets when signing them, and recognized she should have acted to obtain a podiatry consult or add the resident to the podiatry list. When observed by surveyors with unit managers present, all of the resident’s toenails were noted to be thick, long, and curved downward past the nail bed, and the unit managers and leadership staff stated they had not been aware of the condition prior to that observation and that the expectation was for nurse aides to notify nurses so that podiatry services could be arranged.
Failure to Provide Toenail Care
Penalty
Summary
Provide appropriate foot care was cited after the facility failed to ensure Resident #8 received proper toenail care. Resident #8 was an [AGE]-year-old female admitted with diagnoses including metabolic encephalopathy, muscle wasting and atrophy, depression, non-Alzheimer's dementia, hypertension, and heart failure. Her BIMS score was 11, indicating moderate cognitive impairment, and her care plan directed staff to check nail length and trim and clean nails on bath day and as necessary. During observation, her toenails on both feet were noted to be approximately a quarter of an inch past the tip of the toes, with the big toenails curving to the side. Resident #8 stated she had been cutting her own toenails but had recently been unable to bend over to do so, and she said no one had asked to trim them or arrange podiatry care. Interviews showed inconsistent understanding among staff about who was responsible for toenail care. A CNA stated nurses were responsible for trimming toenails unless the resident was diabetic, while an RN stated that because Resident #8 was not diabetic, CNAs were responsible for trimming her toenails. The RN also observed the toenails and stated they were long and needed to be trimmed by podiatry due to the thickness of the big toenails. The Social Worker stated Resident #8 was not being seen by podiatry and that she was waiting for family to sign a podiatry consent. The ADON and DON stated nurses were responsible for trimming toenails unless the resident was diabetic, and both acknowledged the expectation that toenails be checked and trimmed unless the resident refused. The facility policy stated residents unable to perform ADLs independently are to receive services necessary to maintain good grooming and personal hygiene.
Failure to Provide Timely Vascular Referral and Osteomyelitis Treatment for Foot Wound
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and appropriate foot care, including delay in arranging a vascular specialist referral and failure to initiate treatment for osteomyelitis for a resident with peripheral artery disease. The resident had a history of impaired skin integrity to the left fourth and fifth toes, with a care plan goal to prevent complications and an intervention to administer treatments as ordered. On 2/12/26, an NP documented a wound to the left fifth toe and abnormal arterial Doppler results showing mild trifurcation/outflow disease, and ordered a referral to a vascular specialist, expecting the appointment to be made as soon as possible. However, there was no documentation that the facility attempted to make this vascular appointment until 3/24–3/25/26, and the vascular provider confirmed they received the referral only on 3/24/26, with imaging and an office visit scheduled for 3/30/26 and 4/7/26. During this period, the resident’s foot condition progressed. The wound care NP reported being notified on 3/26/26 of an injury to the resident’s left foot and, upon assessing the resident on 3/31/26, found an open wound with drainage on the left fourth toe. She was concerned about an underlying issue needing further investigation but did not have CT results at that time and understood that vascular evaluation was pending. She recommended local wound care (betadine with calcium alginate between the toes and daily dressing changes) until the vascular visit. The wound care NP stated she was not informed that the 3/30/26 CT scan showed osteomyelitis until her next facility visit on 4/7/26, after the resident had already been hospitalized, and indicated that if she had been able to confirm osteomyelitis, she would have recommended an antibiotic. The primary care NP, who would have ordered antibiotics, reported she was not aware of the issue with the fourth toe until after it had already developed and never saw the resident’s left foot after the fourth toe problem was identified. The resident’s family member reported that the foot wound had been ongoing for months, appeared black, and that he repeatedly questioned staff about the condition, stating the resident was not given needed antibiotics and was told they were not necessary. The hospital records documented that the resident presented with a non-healing left foot wound that began as presumed athlete’s foot, later involved the fourth and fifth toes, and continued to deteriorate despite debridement and dressing changes at the facility. The hospital noted the resident had not been seen by a vascular specialist and had not started antibiotics at the facility. Imaging at the hospital confirmed cellulitis and acute osteomyelitis of the left fourth toe, and the resident was started on IV doxycycline and later underwent amputation of the affected toe. These events occurred despite the facility’s written policy stating that staff strive to prevent skin impairment and promote healing through interdisciplinary evaluation and treatment based on clinical best practices.
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