Inaccurate Documentation of Prescribed Heel Protection for At-Risk Resident
Penalty
Summary
The facility failed to ensure accurate clinical record documentation for a resident at risk for skin breakdown who was prescribed heel protection. Multiple observations over several days showed the resident resting in bed with only non-skid socks on, and the prescribed Prevalon heel protection boots were not in use or visible in the area. Despite this, the Treatment Administration Record (TAR) indicated that staff had documented the resident as wearing the Prevalon boots on all shifts for several days. Interviews with staff, including a Qualified Medication Aide and the Director of Nursing, confirmed that the resident usually refused to wear the boots and that the TAR should have reflected these refusals. The resident involved had diagnoses including traumatic brain injury, history of transient ischemic attack, and abnormalities of gait and mobility, and was assessed as cognitively intact and at risk for skin breakdown. Physician orders required the application of Prevalon boots while the resident was in bed, with no end date specified. Facility policies provided by the Director of Nursing required accurate medical records and administration of treatments as prescribed. The documentation in the clinical record did not accurately reflect the resident's non-compliance with the prescribed heel protection, resulting in a deficiency.