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Based on document review, policy review, record review and interview, the hospital failed to have an organized nursing service which provided ongoing assessments of patients' needs and developed a plan of care in order to ensure they provided the services to meet those needs for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Patient #1 presented to the hospital's emergency department (ED) on 10/10/2020 with complaints of left foot pain and was admitted as an inpatient with diagnoses including cellulitis of the left foot.
See A396 for additional information regarding the admission of Patient #1.

2. Review of the nursing assessments of the patient's left foot revealed the patient had a diabetic ulcer wound to the left foot. The nurses documented the patient had a dressing to the left foot on some occasions and that there was not a dressing to the left foot on other occasions. There was no documentation of physician orders for a dressing to the left foot diabetic ulcer wound. There was no documentation the nurses performed dressing changes or treatment to the patient's left foot diabetic ulcer wound.
See A396 for additional information regarding the assessments and lack of treatments of Patient #1's left foot diabetic ulcer wound.

3. Review of the plan of care for Patient #1 revealed no documentation of a treatment plan for Patient #1's left foot diabetic ulcer wound. On 10/12/2020, nursing documented Patient #1's left foot diabetic ulcer wound measured 5 centimeters (cm) x 4 cm and had drainage. The patient's plan of care was not revised and updated with interventions and treatment for the draining diabetic ulcer wound to the patient's left foot.
Refer to A396 for additional information regarding the lack of treatment and plan of care for Patient #1's left foot diabetic ulcer wound.

4. On 10/13/2020, Patient #1's spouse requested the patient be discharged from the hospital. The patient's spouse took Patient #1 to the patient's treating Podiatrist the day of hospital discharge. The Podiatrist documented Patient #1's left foot diabetic ulcer wound now measured 7 cm x 4 cm and the patient had developed a new inflamed and irritated area to the top of the left foot.
Refer to A396 for additional information regarding the patient post hospital discharge left foot diabetic ulcer wound.

Based on the World Journal of Diabetes, Practical Guidelines, policy review, record review and interview, the hospital failed to ensure nursing services developed a nursing care plan using an interdisciplinary team (IDT) approach which provided care to meet each patient's needs with an infected foot ulcer wound for 1 of 3 (Patient #1) sampled patients.

The findings included:

1. Review of the Assessment/Reassessment (Adult) policy revealed, "...The Registered Nurse creates an initial plan for care, treatment, and services appropriate to the patient's specific assessed needs and revises or maintains the plan based on the patient's response. Planning for care, treatment, and services is individualized to meet the patient's unique needs and circumstances. Planning for care, treatment, and services involves using an interdisciplinary [IDT] approach when warranted and involves the patient and family to the extent possible...".

Review of the World Journal of Diabetes; August 15, 2014; Volume 5; Issue 4 revealed, "...Wound care plays a pivotal role in the management of diabetic foot ulcer ...The ideal characteristics of a wound dressing are as follows...Maintain a moist wound healing environment... Absorb excess exudate...Not contaminate the wound with foreign particles...Protect the wound from microorganisms...".

Review of the Practical Guidelines on the prevention and management of diabetic foot disease (IWGDF 2019 update). Diabetes Metab Res Rev. 2020 Mar;36 Suppl 1:e3266. doi: 10.1002/dmrr.3266. PMID: 32176447.John Wiley and Sons; Date: Mar 16, 2020 revealed, "...Local ulcer care...Select dressings to control excess exudation and maintain moist environment...".

2. Medical record review for Patient #1 revealed the patient presented to the hospital's Dedicated Emergency Department (DED) on 10/10/2020 at 5:25 PM with the chief complaint of foot pain.

Review of the DED physician note dated 10/10/2020 at 8:01 PM revealed, "...Patient presents with infection to his left foot...", and the patient had an ulcer with necrotic tissue to the left outer foot close to the toe and an area with erythema back towards the outer left ankle.

Review of the 10/10/2020 x-ray of Patient #1's left foot revealed, "...There is decreased mineralization of the head of the fifth metatarsal suspicious for possible osteomyelitis..."

Patient #1 was admitted as a hospital inpatient on 10/10/2020 at 8:37 PM with diagnoses which included cellulitis of the left foot, infected diabetic foot ulcer, Diabetes Mellitus (DM), Chronic Kidney Disease (CKD), Congestive Heart Failure (CHF), and Chronic Neuropathy to bilateral lower extremities. Review of the physician's orders revealed there was no order for dressings or wound care to Patient #1's left foot diabetic ulcer wound.

Review of Patient #1's skin assessment flowsheet dated 10/10/2020 at 11:18 PM revealed Registered Nurse (RN)
#5 documented Patient #1 had a diabetic ulcer wound to the left outer foot. There was no documentation addressing the size of the ulcer wound. RN #5 documented, "Dressing Status...Clean; Dry; Intact" and the wound site had "Black; Dark edges." There was no documentation the RN performed wound care or re-applied a dressing. There was no documentation the RN contacted the IDT to develop a plan to address the patient's wound.

Review of the Patient #1's nursing care plan dated 10/10/2020 revealed no documentation of treatment or interventions to address the patient's infected left foot diabetic ulcer wound.

On 10/11/2020 at 7:46 AM, RN #1 documented that Patient #1's ulcer wound was, "Clean; Dry, Intact...Unable to assess". There was no nursing plan of care to address the ulcer wound.

Review of Patient #1's skin assessment flowsheet dated 10/11/2020 at 4:05 PM revealed RN #1 documented Patient #1 had a diabetic ulcer wound to the left outer foot and, "Dressing Status...Removed", and the wound site was black with eschar. RN #1 documented the wound drainage was "None."

Review of the nursing care plan dated 10/12/2020 revealed the problem of "Skin Injury Risk Increased" with the intervention of "Optimize Skin Protection". The care plan did not address the patient's left outer foot diabetic ulcer wound, treatment or dressing changes for the diabetic ulcer wound.

Review of Patient #1's skin assessment flowsheet dated 10/12/20 at 12:32 AM revealed RN #2 documented the patient had a diabetic ulcer wound to the left outer foot and the, "Dressing Status...open to air" and the wound site was black with eschar and had red serosanguinous drainage. There was no documentation the nursing plan of care had been updated to address the patient's ulcer wound.

Review of the nursing note dated 10/12/2020 at 12:33 AM revealed RN #2 documented, "It was noted that the patient has a 5 cm [centimeter] x 4 cm wound to his left outer foot...The patient states that it has been draining. There is redness that tracks up to his anklebone on his left foot. The wound is open to air...".

Review of a nursing note dated 10/12/2020 at 2:41 PM revealed RN #3 documented, "Attempted to contact [Name of Physician #1] about wife's concerns about sending [Patient #1] home without being sure if patient has osteomyelitis...Wife would like an infectious disease to see the pt [Patient #1]..."

Review of Patient #1's skin assessment flowsheet dated 10/12/20 at 3:43 PM revealed RN #4 documented the patient had a diabetic ulcer wound to the left outer foot and the dressing status was "Clean; Dry; Intact" and the wound site was black with eschar. There was no documentation Patient #1's nursing care plan had been updated with interventions for treatment of the diabetic ulcer wound dressing or physician notification for orders for a wound dressing.

Review of the Infectious Disease (ID) consult dated 10/12/2020 at 11:00 PM revealed Patient #1 had seen by his Podiatrist last week and the patient's diabetic ulcer wound was thought to be improving. The ID documented the patient has "developed increased local redness and discoloration of the site with some oozing" and, "...There are ulcerative changes over the lateral left foot. There is some dark areas of discoloration..."

Review of the "Orthopedic Surgery Consultation" note dated 10/13/2020 at 8:23 AM revealed prior to Patient #1's hospitalization, the patient had been seeing a Podiatrist weekly for treatment of the left foot ulcer and the patient's spouse did local wound care daily with Adaptic, silver nitrate and wet to dry dressings. The Orthopedic Surgeon documented the patient and spouse were hopeful that with continued wound care the diabetic wound ulcer would subside...".

Review of the ID note dated 10/13/2020 at 9:11 AM revealed, "...His wife reports that she has spoken with [Patient #1's] podiatrist and they have an appointment this afternoon and would like to be discharged...His left foot dressing was just changed. I did review recent pictures with his wife on her phone..." There was no documentation on the patient's care plan or physician orders for the type of treatment to be performed to the diabetic ulcer wound or the type of dressing change for the diabetic ulcer wound.

Review of the 10/13/2021 Discharge Summary conducted by Physician #1 revealed, "[Patient #1]...podiatrist noticed swelling and erythema of his foot and [Patient #1] was sent to the ER [emergency room] for admission and IV AB's [Intravenous Antibiotics] [Patient #1] was seen in consultation by Ortho [Orthopedics] and ID [Infectious Disease]...A bone scan was ordered but the wife did not want to wait the results and insisted on taking him home. [Patient #1] will need close follow up and proper wound care..."

Patient #1 was discharged from the hospital on 10/13/2020.

3. In a telephone interview with the Administrative Director of Clinical Services (ADSC) and Physician #1 on 3/22/2021 at 11:34 AM, Physician #1 stated Patient #1's left foot wound did not worsen nor did the patient develop new wounds while hospitalized. When asked about his documentation that Patient #1 was sent to the hospital's ER from the Podiatrist's office, Physician #1 stated he might have been confused about the patient being sent to the hospital's ER from the Podiatrist's office.

In a telephone interview on 3/22/2021 at 2:13 PM, the ADCS stated Patient #1's spouse applied dressings to Patient #1's diabetic ulcer wound while the patient was in the hospital. The ADCS verified there were no orders for dressings to the patient's wound or pictures of the wound in the patient's records.

In a telephone interview on 3/23/2021 at 3:06 PM, the ADCS stated she had spoken with Physician #1 regarding why he did not order diabetic ulcer wound care for Patient #1. The ADCS stated Physician #1 said he didn't order diabetic ulcer wound care because he was waiting on an MRI to see if the patient had Cellulitis or Osteomyelitis.

A telephone interview was conducted on 3/24/21 at 3:34 PM with Patient #1 and the patient's spouse. Patient #1's spouse stated she did start putting wound dressings on Patient #1's diabetic ulcer wound on 10/12/2020 because the hospital kept "putting on the same dirty sock" on the patient's left foot diabetic ulcer wound. The patient's spouse stated she had asked the nurses about treatment and dressings for the patient's diabetic ulcer wound to the left foot and the nurse had told her that there was no order for treatment or dressing change to the patient's left diabetic ulcer wound. Patient #1 stated the hospital staff took the dressing of his foot in the emergency room and never put another dressing back on his foot. Patient #1 stated the hospital just kept putting the same dirty sock on his left foot diabetic ulcer wound.

A telephone interview was conducted with the Patient #1's Podiatrist on 3/24/21 at 6:23 PM. The Podiatrist was asked to verify if Patient #1 was seen in his office on 10/13/2020 following hospital discharge and to describe the patient's left foot wound(s). The Podiatrist verified Patient #1 was seen in his office on the afternoon of 10/13/2020 following hospital discharge and stated Patient #1's diabetic ulcer wound at that time measured 7 cm x 4 cm with necrosis (eschar) in the center of the ulcer wound. The Podiatrist stated a new area had developed on top of the Patient #1's left foot that was inflamed and irritated. The Podiatrist stated the last time he had seen Patient #1 was on 10/5/2020 and the patient's left foot diabetic ulcer wound measured 2.8 cm x 2.6 cm at that time.