Failure to Provide Ordered Foot and Nail Care Resulting in Painful Overgrown Toenails
Summary
The facility failed to provide appropriate foot and nail care to one resident who had a physician’s order for routine nail care. The resident was admitted with hemiplegia/hemiparesis affecting the left side and peripheral vascular disease, and was assessed as cognitively intact on the MDS, requiring substantial/maximal assistance with bathing and supervision/touching assistance for personal hygiene. A physician’s order dated 5/12/24 directed that nail care could be provided once every four weeks on Sundays, but the resident’s left toenails were observed to be very long, overgrown past the tips of the toes, sharp-edged, dirty, and discolored yellow and dark brown, and had not been trimmed for several months. During observation and interview, the resident was noted to be wearing a sock and shoe only on the right foot, with the left foot bare. The resident reported having repeatedly asked staff to trim his toenails and stated he could not wear a sock or shoe on the left foot because the long toenails caused pain when he tried. The resident further reported that CNAs and licensed nurses told him they could not cut his toenails and that he would be charged $50 for the service. CNA staff confirmed that the resident’s toenails were long, sharp, discolored, and had not been trimmed for a long time, and stated that when a resident refused hygiene care, they were expected to notify the nurse so the nurse could encourage cooperation and explain risks. Interviews with nursing and social services staff showed that the facility had processes for nail care and podiatry services that were not followed for this resident. The LN stated that podiatry visited monthly and that residents could be added to the podiatry list based on nursing assessment or CNA reports, and that LNs could trim toenails with a doctor’s order, with refusals documented in progress notes and the physician notified. The Social Services Director reported that the resident was not on the podiatry list and had no record of prior podiatry visits. The DON confirmed there were no progress notes or other documentation of the resident refusing toenail care, despite staff claims of refusal, and verified the existence of the standing nail care order and the poor condition of the resident’s toenails. Facility policies on ADLs and nail care required provision of hygiene and nail care, consultation with an RN for special directions, and documentation of nail care provided, which were not carried out in this case.
Penalty
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Below are regulatory guidelines relevant to this citation:
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.
A diabetic resident with impaired cognition and vascular dementia, who required assistance with mobility and toileting, did not receive routine foot and nail care despite a care plan directing staff to monitor skin and provide ordered treatments. Physician orders for the month lacked any nail care directives, and there was no documentation that nail care had been performed. Although podiatry services were eventually authorized by the resident’s durable power of attorney, observations later showed the resident complaining of foot pain, with overgrown, curling toenails causing reddened indentations on adjacent toes and white tissue noted between and along the toes.
Failure to Provide Timely Podiatric Care: A resident with DM, diabetic polyneuropathy, and significant ADL assistance needs had active orders for podiatry and diabetic foot care, but the record showed no podiatry evaluation and the resident was not seen by podiatry. During observation, the resident’s bilateral feet had long, jagged toenails, and the UM and ADON confirmed the nails were long.
A resident with multiple comorbidities did not receive wound care as ordered for an arterial ulcer on the right foot, and comprehensive assessment of a surgical wound following amputation was not completed. Documentation was lacking for both the administration of wound care and the assessment of the surgical site, as confirmed by facility leadership.
A resident with cognitive deficits and a history of combative behavior was observed with extremely long, thick, and curled toenails after repeatedly refusing nail care from staff and a podiatrist. Staff and medical record reviews revealed a lack of documentation regarding family notification and care conference discussions about the refusals, despite facility policy requiring proper foot care and communication.
A resident with multiple medical conditions was not provided timely podiatry care due to a delay in obtaining consent for auxiliary services and a lack of awareness among staff. The resident was observed with long, thickened, yellow toenails, and staff interviews confirmed there was no specific policy for podiatry services, resulting in the resident missing needed foot care.
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 Routine Foot and Nail Care for Diabetic Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure routine foot care for a diabetic resident with impaired cognition and vascular dementia. The resident was admitted with diagnoses including acute and chronic heart failure, type 2 diabetes, and vascular dementia, and required setup assistance for eating and moderate assistance for toileting, bed mobility, and transfers. The care plan identified diabetes mellitus with insulin dependence and included interventions such as blood glucose monitoring, diet and medications as ordered, and checking the body for skin breaks. However, review of the physician’s orders for the relevant month showed no orders related to nail care, and the facility was unable to locate any documentation that nail care had been provided. The resident’s quarterly MDS showed impaired cognition without behaviors or rejection of care. The resident initially did not authorize podiatry services per a consent form, but a later podiatry services authorization form showed that the durable power of attorney consented to podiatry services. A weekly nursing skin and body review documented a head-to-toe assessment with no new skin areas noted shortly before the deficiency was identified. Subsequent observations revealed the resident attempting to self-propel in a wheelchair, bumping her foot and stating that it hurt. A focused observation of the left foot showed overgrown nails on the third and fourth toes extending past the end of the toes and curling toward adjacent toes, causing reddened indentations where they touched. The great toe had white-colored tissue at the end of the toe, between the great and second toes, and along the side of the second toe, and the resident complained of pain when questioned by staff. These findings demonstrated that routine foot and nail care had not been provided as needed for this diabetic resident.
Failure to Provide Timely Podiatric Care
Penalty
Summary
The facility failed to provide timely podiatric care for a resident with multiple medical conditions, including spinal stenosis, a thoracic compression fracture, type II diabetes mellitus with diabetic polyneuropathy, and hypertension. The resident’s admission MDS showed a BIMS score of 7 and documented that the resident required substantial to maximal assistance with putting on and taking off footwear. The care plan stated the resident was assisted with all ADLs, including grooming, and included interventions for diabetic nail care and assistance with nails, shaving, and hair as needed. The resident had active physician orders for podiatry to evaluate the feet as indicated for foot care and for diabetic shoes, as well as an order for caregiver foot care including washing, drying, applying lotion, and checking for skin concerns. However, the medical record contained no documented podiatry progress note or evaluation, and the completed podiatry appointment record confirmed the resident was not seen by podiatry. During observation, the resident’s bilateral feet were exposed and the toenails were long and jagged. The Unit Manager and ADON confirmed the toenails were long and stated the wound nurse practitioner would trim them that day.
Failure to Provide Ordered Wound Care and Comprehensive Wound Assessment
Penalty
Summary
The facility failed to provide wound care as ordered for an arterial ulcer on a resident's right foot and did not complete a comprehensive wound assessment for a surgical wound on the same resident. Medical record review showed that the resident, who had diagnoses including COPD, diabetes mellitus, and peripheral vascular disease, was admitted with an arterial ulcer on the right foot second digit. Orders were in place for daily and as-needed application of barrier spray/wipes, but documentation on the Treatment Administration Record did not support that these treatments were completed as ordered. The wound physician's note and physician orders specified the required care, but the order was incorrectly entered into the electronic health record as 'as needed' only, rather than 'daily and as needed.' The resident later complained of the toe being dead, was hospitalized, and subsequently underwent amputation procedures. Further review of the medical record after the resident's return from the hospital revealed incomplete documentation regarding the surgical wound. Admission and weekly skin assessments noted the presence of amputated toes but did not include measurements or descriptions of the surgical site. Interviews with the Administrator and DON confirmed the lack of documentation for both the wound care provided and the assessment of the surgical wound, which was not in accordance with the facility's wound care policy that requires detailed recording of wound care and assessments.
Failure to Provide Adequate Foot Care Due to Incomplete Documentation and Communication
Penalty
Summary
The facility failed to provide adequate foot care for a resident with a history of traumatic brain injury, aphasia, and cognitive deficits. The resident was noted to have self-care deficits and was frequently resistive or combative during attempts at nail care, both by staff and an outside podiatrist. Despite repeated refusals, there was no documentation that the resident's family was notified of the ongoing issue, nor was there evidence that refusals were discussed during care conferences. Observations revealed the resident's toenails were extremely long, thick, and curled, and staff interviews confirmed awareness of the resident's refusal and the lack of a clear plan to address the situation. Medical record reviews showed multiple missed opportunities to document and communicate the resident's refusals and the resulting condition of her toenails. The facility's policy required ensuring proper foot care, but interventions such as reapproaching the resident or educating the family were not consistently documented or implemented. The podiatrist suggested the possibility of sedation to facilitate nail care, indicating the chronic nature of the problem, but there was no evidence that this recommendation had been acted upon or communicated to the family.
Failure to Provide Timely Podiatry Services
Penalty
Summary
A deficiency was identified when a resident did not receive timely podiatry services. The resident, who had diagnoses including muscle weakness, vascular dementia, and epilepsy, was observed to have long, thickened, yellow toenails on both great toes. Review of the medical record showed that although the resident was readmitted to the facility, a consent for auxiliary services, including podiatry, was not obtained until several weeks later. During this period, the resident did not receive podiatry care, and the need for such services was not recognized until a care conference was held. Interviews with facility staff confirmed that there was no specific policy in place for podiatry services, and the social services designee was unaware of the resident's need for podiatry until the care conference. The podiatrist's last visit to the facility occurred prior to the consent being obtained, and the next scheduled visit was after the deficiency was identified. The lack of timely consent and absence of a clear process for arranging podiatry services led to the resident not receiving necessary foot care.
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