See event ID PY0C12. Based on interview, and record review, facility staff failed to maintain professional standards of practice when staff failed to document wound treatments for one resident (Resident #1), whose wound became infected, out of three sampled residents and failed to perform neurological assessments for one resident (Resident #1) out of three sampled residents after a fall. The facility census was 51.

Based on interview, and record review, facility staff failed to maintain professional standards of practice when staff failed to document wound treatments for one resident (Resident #1), whose wound became infected, out of three sampled residents and failed to perform neurological assessments for one resident (Resident #1) out of three sampled residents after a fall. The facility census was 51. 1. Review of the facility's policy titled, Physician Orders, dated 02/2022, showed staff are directed to follow physician's orders. Physician's orders will be entered into the electronic medical record (EMR) as soon as practicable once received from the physician. Orders will be carried out as per the physician. Review of the facility's Fall Risk Reduction policy, dated 10/2011, showed if the fall is un-witnessed and if the resident is not able to definitively validate that he/she did not strike his/her head, implement neurological checks and continue for seventy-two hours. Schedule for Neurological Assessment Following Potential Head injury every fifteen minutes times four, every sixty minutes times four, every four hours times four, every shift for seventy-two hours. Review showed it did not contain direction for staff regarding not performing Neurological Assessments following a potential head injury if the resident is at the end of life. 2. Review of Resident #1's Significant Change in Status Assessment (SCSA) Minimum Data Set (MDS), a federally mandated assessment tool, dated 08/20/24, showed staff assessed the resident as severely cognitively impaired and did not contain documentation of a fall since admission or rejection of care. Review of the podiatrist's orders, dated July 2024, showed: -On 07/17/14: Keep Mepitel dressing (a thin transparent dressing) and Steri-Strip intact on the left great toe, paint incision with Betadine on side of left foot, cover both wounds with plenty of 4x4 gauze to increase padding, cover with rolled gauze and ACE bandage and change bandage every other day. -On 07/22/24: Cleanse the wound on the great toe and left lateral foot with saline or wound cleanser, pat dry, and apply dry dressing daily and as needed, if soiled; Review of the resident's Physician Order Sheet (POS), dated 07/01/2024 to 08/31/2024, showed the POS did not contain: -Orders to keep Mepitel dressing and Steri-strip intact on the left great toe, paint incision with Betadine on side of left foot, cover both wounds with plenty of 4x4 gauze to increase padding, cover with rolled gauze and ACE bandage and change bandage every other day; -Orders to cleanse wound on the great toe and left lateral food with saline or wound cleansers, pat dry, and apply dry dressing daily and as needed, if soiled. Review of the resident's Treatment Administration Record (TAR), dated July 2024, showed: -On 7/13/24: Paint the left foot incision with Betadine daily, cover with a 4x4 gauze, wrap with gauze and ACE wrap daily every evening for surgical wound to left foot. Review showed the TAR did not contain documentation staff provided wound care on 07/14/24, 07/18/24, 07/25/24, and 07/26/24; -Review showed the TAR did not contain contain the podiatrist's orders to cleanse the wound on the great toe and left lateral foot with saline or wound cleanser, pat dry, and apply dry dressing daily and as needed, if soiled. Review of the Podiatrist progress notes, dated 07/31/24, showed he/she placed a call placed to nursing home to discuss why patient presented today without proper bandages and proper wound care. He/She explained that patient was at risk for further amputation due to now infected wounds not being properly cared for in facility. Review of the resident's podiatrist orders, dated 07/31/24, showed an order to Apply Betadine to the incision site and to the great toe wound, apply Aquacel AG (a wound dressing that combines hydrofiber technology with ionic silver to treat wounds), cover both sites with gauze, cover with rolled gauze and ACE bandage daily. Foot is to stay wrapped and covered at all times. Doxcycline Monohydrate (used to treat infections) 100 milligram (mg) by mouth two times a day for ten days. Further review of the resident's Treatment Administration Record (TAR), dated July 2024, showed an order dated 7/31/24 to check the left foot each shift, ensure dressing/ace wrap in place, clean and dry, and change dressing once daily and as needed. The TAR showed it directed staff to do the treatment on an as needed basis and not daily per the podiatrist's orders. Review showed the TAR did not contain documentation staff provided wound care on 07/31/24. Review of the Podiatrist office note, dated 10/23/24, showed the physician documented the resident's wound not bandaged. The wound was infected. Review of the resident's medical record, dated, 08/19/24, showed staff documented the resident had an unwitnessed fall. Review of the resident's neurological Assessment Flow Sheet, dated 08/19/24 through 08/23/24, showed the flow sheet did not contain documentation of neurological assessments or vital signs as directed by the facility's policy, for the dates of 08/19/2024 through 08/23/2024. During an interview on 10/23/24 at 12:03 P.M., LPN A said staff are directed to assess the resident after an unwitnessed fall, or a witnessed fall with head injury, and complete neurological checks for seventy-two hours. The LPN said staff would document the neurological checks on a form. Staff should continue neurological checks even if the resident is towards the end of his/her life. During an interview on 10/25/24 at 1:08 P.M., Licensed Practical Nurse (LPN) A said he/she did not know why the wound care was not completed as ordered. He/She said if a wound care treatment was not completed, staff are too report to the DON. He/She said he/she did not know if the resident's wound became infected, due to the treatments not being completed according to physician orders. During an interview on 10/25/24 at 1:25 P.M., the Director of Nursing (DON) said the resident's family member would take the resident to his/her appointments without informing staff, so staff may not have known to ask if there were new orders from the Podiatrist. He/She did not know who or why the sutures were removed and would need to look in to it. Staff are directed to assess the resident, ensure resident safety, notify the physician, family and himself/herself after a fall. The DON said if the fall is unwitnessed, or a witnessed fall with head injury, staff are directed to perform neurological checks for seventy-two hours. The hospice nurse was in the resident's room from the hours of 7:15 P.M. through 11:15 P.M. on 08/19/24, so staff did not perform neurological checks. The resident's daughter signed a comfort measure form, so staff did not conduct a neurological assessment from 11:00 P.M. to 7:00 A.M. on 08/20/24 through 08/23/24. During an interview on 10/25/24 at 1:26 P.M., the administrator said the resident's family member took the resident to his/her doctor appointments and he/she did not know if the family member provided staff with any new orders. He/She said staff may not have known the resident went to a podiatrist appointment if the residents family member did not tell facility staff. If a resident had a unwitnessed fall, or witnessed fall with head injury, staff are directed to ensure resident safety, conduct an assessment, notify the physician, family, and DON, and start and neurological and vital checks to be completed for seventy-two hours. Staff are educated to follow fall protocol. The staff did not complete neurological checks during the hours of 7:15 P.M. through 11:15 P.M. on 08/19/24, since the hospice nurse was with the resident. The staff did not perform neurological checks from 11:00 P.M. to 7:00 A.M. on 08/20/24 through 08/23/24 because of the resident's state of medical condition it was the towards the end of his/her life. 4. During an interview on 10/25/24 at 1:08 P.M., LPN A said nurses are responsible to update physician orders as soon as received. The LPN said staff are expected to follow the prescribed orders and should document completed treatments on the TARS. The LPN said if a treatment is missing from the TAR it should be reported to the DON. LPN A said The DON was responsible for ensuring orders are transcribed accurately. During an interview on 10/25/24 at 1:25 P.M., the DON said the charge nurse is responsible for contacting the physician to obtain a verbal order or the wound care nurse should document the orders in the wound care book. The DON said the nurses are responsible for transcribing orders in the residents' medical records. The DON said if staff questioned the orders, they would need to clarify with the physician or other provider. There is no auditing system in place to ensure the orders are transcribed accurately in the resident's medical record. If staff did not follow wound care orders, there is the potential a wound could become infected. He/She said he/she did notice staff did document providing treatments on the TAR. He/She said he/she had not had an opportunity to review why there were undocumented treatments, so he/she did have a reason why. He/She said staff have to select to add the order to the TAR or the order will not transfer over to the TAR. He/She said During an interview on 10/25/24 at 1:26 P.M., the administrator said the nurse would get the orders from the wound care nurse, or physician, based on what was observed. He/She said the orders are transcribed by the nurse into the resident's medical record. He/She said if the nurse had questions about the orders, he/she would clarify with the nurse practitioner or the physician. He/She said there was no audit in place to ensure the orders were transcribed accurately into the resident's medical record. He/She said the staff were expected to double check the information being entered for accuracy. He/She said when a resident goes to an appointment outside the facility, they do have communication with the physician. He/She said the resident, family member, or attendant were given paperwork to give to the physician's office, which included, the facility fax number to fax over new physician orders. He/She said if staff did not follow wound care orders, there was a potential to cause an infection in the wound. MO00243904

Based on interview and record review, facility staff failed to notify one resident's (Resident #1) family and physician in a timely manner when staff identified the residents second and third toes on his/her right foot swollen, red, white, macerated, draining serosanguinous fluid (contains or relates to both blood and the liquid part of blood (serum) which resulted in the resident being sent to the hospital and his/her second right toe amputated. The facility census was 50. 1. Review of the facility policy change of condition, revised February 2019, showed staff are directed to observe, record, and report any condition change to the attending physician to ensure proper treatment will be implemented. Review showed staff are directed to notify the resident's responsible party. 2. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument, dated 12/27/23, showed staff assessed the resident's diagnoses included peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), cellulitis (infection of the deep tissues of the skin and muscle) of the right lower limb, diabetes mellitus (group of diseases that result in too much sugar in the blood), diabetic neuropathy, and dementia. Review of the resident's plan of care, updated 1/17/24, showed staff assessed the resident with impaired skin integrity due to history of rashes and sores on feet and toes. Review showed staff identified the resident diagnosed with diabetes mellitus. Review showed staff documented interventions to monitor, document, and report as needed any signs and symptoms of infection to any open areas, redness, pain, heat, swelling or pus formation. Review showed staff are to check the residents skin for breaks and treat promptly as ordered by doctor. Review of the resident's nurses notes, dated 2/22/24 at 6:26 A.M., showed staff documented the resident with a blister like reddened are on his/her right foot great toe. Review showed staff covered the area with a dressing. Review of the resident's nurses notes, late entry for 2/25/24 at 6:45 A.M., created 2/28/24 at 2:38 P.M., showed Licesned Practical Nurse (LPN) C documented the resident's right foot second toe red and swollen. Review showed LPN C documented he/she reported to the day shift nurse to consult physicain with condition and addtitional orders. Review of the resident's nurses notes, late entry for 2/25/24 at 2:58 P.M., created 2/28/24 at 3:04 P.M., showed LPN A documented the resident right foot toes blisters opened, foul odor, and purulent (containing or producing pus) drainage present. Review showed the nurses note did not contain documentation staff notified the doctor or family of the change in condition. Review of the resident's nurses notes, dated 2/28/24 at 4:29 P.M., showed LPN C documented the residents second and third toes on right foot swollen, red, white, macerated, draining serosanguinous fluid and very foul odor. Review showed LPN C documented the bulb of toes completely open and macerated (the softening and breaking down of skin). Review showed the wound nurse consulted and advised to send the resident to the emergency room for evaluation and rule out osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection). Review of the resident's emegency room paperwork, dated 2/28/24 showed hospital staff documented primary diagnosis as Type 2 diabetes mellitus with diabetic foot infection with redness, swelling, and drainage noted to right 2nd toe. Review of the hospital medical records, dated 2/29/24 through 03/02/24, showed staff documented an impression of cellulitis around the foot particularly around the 2nd and 3rd toes, ulceration along the distal aspect and plantar aspect of the 2nd toe, and necrotic (the death of body tissue) tissue on the 2nd toe with probable osteomyelitis and septic arthritis. Review showed hospital staff documened the final diagnoses included type 2 diabetes mellitus with foot ulcer, type 2 diabetes with diabetic peripheral angioplasty (disease of the blood vessels) with gangrene (death of body tissue due to a lack of blood flow or a serious bacterial infection), other acute osteomyelitis of the right ankle and foot, gangrene and cellulitis of the right toe. Review showed the operation notes, dated 3/2/24, amputation of the second toe of the right foot and debridement (removal) of necrotic wounds on the third toe of the right foot. During an interview on 3/11/24 at 10:45 A.M., LPN A said he/she observed foul, purulent-looking drainage on 2/25/24, and he/she noticed blisters on the resident's three toes on the right foot had popped and were draining. LPN A said he/sh planned on calling the doctor but got busy and forgot. During an interview on 3/11/24 at 2:17 P.M., the Director of Nursing (DON) said he/she is not aware of staff calling the residents doctor after LPN A observed the residents toes on 2/25/24 until 2/28/24. During a telephone interview on 3/12/24 at 9:48 A.M., the resident's family member said when the resident went to the hospital on 2/28/24, hospital staff found the resident had a staph infection in his toes and removed the 2nd toe on his/her right foot. During a telephone interview on 3/12/24 at 12:29 P.M., LPN C said he/she worked the overnight shift from 2/24/24 to 2/25/24. LPN C said when he/she observed the resident's foot at 5:00 A.M. on 2/25/24 the 2nd toe on the right foot was red, angry, and swollen. LPN C said he/she told the day shift nurse to call the doctor about the toe and get an order. LPN C said on 2/25/24, the 2nd toe appeared like it needed a treatment order from a physician. LPN C said when he/she removed the resident's right sock on 2/28/24, the right sock had drainage saturated on it which smelled terrible, the whole top of the foot was red, the pads on the bottom of the 2nd and 3rd toe were visibly open, and both toes were dripping serosanguinous drainage. LPN C said he/she came in early in the morning on 2/28/24 and the wound nurse was on-site at the time, so he/she asked the wound nurse to look at the resident's toes. LPN C said later in the day, he/she discovered the wound nurse had left without examing the resident's toes. LPN C said he/she observed the foot and then called the wound nurse and the physician to update them on the condition. The LPN said the wound nurse and physician advised sending the resident out to the emergency room for evaluation and treatment. During a telephone interview on 3/12/24 at 3:11 P.M., the resident's physician said if staff observed a resident's toes with foul-smelling purulent drainage, he/she expected staff to notify him/her of this on the same day. During a telephone interview on 3/14/24 at 8:57 A.M., LPN A said he/she forgot to notify the resident's family about the toe on 2/25/24 because he/she was so busy that day. During a telephone interview on 3/20/24 at 9:27 A.M., the DON said given the condition of the resident's foot as observed by LPN A on 2/25/24, he/she would have expected staff to notify both the physician and family as soon as possible. He/She did not know why staff failed to do so. MO00232536 & MO00232506