Penalty

Fine: $8,788

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Nursing staff failed to ensure timely clarification and follow-up on wound care recommendations for a resident with multiple wounds and complex medical conditions, including diabetes, multiple myeloma, chronic thrombocytopenia, anemia, and a recent right toe amputation. The resident was seen at an outside wound clinic, where recommendations for an X-ray of the right foot to rule out osteomyelitis were made on multiple occasions. Despite these recommendations, there was no documentation that nursing staff clarified the responsibility for obtaining the X-ray or followed up with the clinic after the appointments. The wound clinic's notes indicated that an X-ray order was placed in their system and could be completed at a hospital, but the clinic did not have X-ray capabilities. The facility staff, including the unit manager, reviewed the consultation notes but found them ambiguous and believed the wound clinic was responsible for obtaining the X-ray. It was not until a month after the initial recommendation that the unit manager contacted the wound clinic for clarification and learned that the facility was expected to obtain the X-ray. As a result, the X-ray was delayed and only completed after clarification was sought, ultimately confirming the presence of osteomyelitis in the resident's right third toe. The delay in obtaining the X-ray was due to a lack of timely communication and clarification between the facility nursing staff and the wound clinic regarding responsibility for carrying out the recommended diagnostic test.