LVN 3 at Madera Post Acute Center admitted to inspectors that the wounds "may not have ruptured and opened" if the resident's doctor had been contacted when swelling first increased on January 15, 2025.
The resident, identified as Resident 8, had been readmitted to the facility in May 2024 with type 2 diabetes, diabetic neuropathy, and chronic kidney disease. The resident used a wheelchair and required assistance with bathing and transfers, but had intact cognition.
On January 15, LVN 3 observed increased swelling in Resident 8's left foot. The nurse told inspectors this was a significant change from the resident's baseline condition. LVN 3 knew swelling indicated circulation problems that could lead to ulcers and wounds on legs, feet, and toes.
Despite recognizing the change, LVN 3 failed to complete a required change of condition form or notify the resident's physician.
The next day, January 16, the swelling remained the same. Again, LVN 3 took no action to alert medical staff.
On January 17, the swelling persisted and Resident 8's second and third toes developed open wounds. Only then did LVN 3 complete a change of condition form, two days after first noticing the problem.
By February 5, when inspectors arrived, Resident 8's left second and third toes had turned black and purple. The great toe was swollen with purple discoloration and partially opened. The entire left foot showed "plus 4 pitting edema" — severe swelling that leaves deep indentations taking more than 30 seconds to disappear.
LVN 3 told inspectors the toe wounds had not improved by January 20 and had actually gotten worse. The nurse acknowledged this should have triggered another physician notification and change of condition form, but neither occurred.
"Not notifying Resident 8's physician in a timely manner put Resident 8 at risk for developing further skin breakdown," LVN 3 admitted to inspectors. The nurse explained that toe wounds "could get worse in a matter of days and cause irreversible damage when the wounds were not treated in a timely manner."
The facility's own policy required nurses to notify physicians of any change in resident condition, including "change in ability or decline in physical function" and "any signs or symptoms of infections." The policy mandated at least three days of observation and documentation following any change.
LVN 3 explained that when a change of condition form is created, licensed nurses must monitor the resident's condition for 72 hours and follow up with the physician if the condition doesn't improve or worsens. The nurse was only "visually monitoring" the swelling rather than following proper protocols.
Director of Nursing confirmed that edema or swelling in legs constituted a change of condition requiring physician notification. The DON explained that doctors need to evaluate residents with new swelling to rule out cardiovascular problems, since edema signals circulation issues that can lead to foot and toe wounds.
"Had Resident 8's physician been informed on 1/15/2025 that Resident 8 had an increase in swelling to the left feet and legs, it was possible Resident 8's toe wounds may not have developed and/or opened," the DON told inspectors.
The DON also confirmed that when Resident 8's toe wounds worsened by January 20, a new change of condition form should have been completed due to the severity of the resident's vascular problems.
The resident's care plan, updated in January, included monitoring for signs of infection such as green drainage, foul odor, redness, and swelling. Staff were supposed to document wound healing progress and notify physicians as needed.
Federal inspectors cited the facility for failing to ensure residents received necessary care and services. The violation was classified as causing minimal harm with potential for actual harm, affecting few residents.
The inspection occurred following a complaint about the facility's care practices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Madera Post Acute Center from 2025-02-05 including all violations, facility responses, and corrective action plans.