Why You Should Look… Even Where The “Sun Does Not Shine”

Recently I worked with a client whose father had been in the nursing home for “rehab” after a stroke. Due to various events, the son was unsettled and felt unhappy about how his father was progressing or, I should say, was not progressing.

One of the goals for the father was to pivot safely, gain strength and hopefully go home with caregiver assistance.

There was to be physical therapy twice a day to regain strength and be able to at least pivot on his “good” foot so transfers to the toilet, chair, and back to bed could be done with the patient’s assistance.

However, the patient refused to transfer due to pain in his right leg and foot. He continuously complained of pain until he finally wheeled himself to the nurses’ station.

He demanded to be seen by a doctor to look at his foot and receive something for pain. And he made it clear that he was not leaving until a doctor saw his foot. Fortunately, this patient could wheel himself to the nurse’s station.

This happened around supper time when the son was arriving to visit. When he found out his father was at the nurses’ station and why he looked at his father’s foot.

I asked the son if he had ever looked at his father’s feet before? If he had ever removed shoes and socks to inspect the toes and heels? Sadly, he had not. He had not looked, as I call it, “where the sun does not shine.”

Once the son checked his father’s foot, the big toe was infected with a black, ingrown toenail. On the same foot, there was a bandage covering a heel ulcer.

Until that Friday afternoon, the son had assumed the facility staff was taking care of his father’s complaints and never checked his father’s foot.

Pictures were sent to me of the foot and heel. My immediate recommendation was to take his father to the emergency room for evaluation and treatment. Upon arrival at the hospital, his father was assessed in ER and admitted for IV treatment and further assessment.

To add to the complications, the patient was diabetic. Prompt attention and treatment are always necessary for any lower leg, foot, or toe issue in a diabetic patient.

The father had not seen a podiatrist at the nursing home for at least three months. The toenails were long, thick, and unkempt, needing prompt attention.

After the hospital treatment, the father was released and did not return to the original nursing home. He was transferred to another nursing home to be followed and treated by an outside podiatrist not affiliated with the nursing home.

In general, podiatrists only visit a nursing home every three months for general foot care. It is important to note that when in a nursing home, or rehabilitation facility, a patient is allowed to have an outside provider for various medical needs.

In most cases, if the provider is not on staff at the facility, a family member, caregiver or Medivan will have to transport the resident to the outside doctor visits.

After a review of the medical records for this patient, it was documented that he had an ingrown toenail on his great toe (Big toe) for over six months.

The medical records did not support that the podiatrist or any medical provider had seen this ingrown toenail or knew about it. The medical record did not support that any treatment had occurred for the six months since admission.

It was not until the patient demanded to see a doctor for the foot pain and the son took off his father’s sock that an oral antibiotic treatment started.

Additionally, a heel ulcer was begin treated on this same foot. Again, the son did not know about this heel ulcer until he saw the bandage. It was unknown to the resident and the son how long the heel ulcer had been on the foot.

While various issues are of concern with this case, two of them stand out:

• The lack of Quality of Care and treatment 42 CFR 483.25. 
• And the neglect to notify the resident and the power of attorney for health care (in this case the son) of significant changes 42 CFR 483.10(b(11) as required by the nursing standard of care, Federal and State regulations.

No wonder the resident complained of pain, could not transfer with weight-bearing on the foot, and refused to continue with his physical therapy.