Inaccurate Documentation of Resident's Treatment Administration Record for Heel Protector Boots
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's Treatment Administration Records (TAR) regarding the use of heel protector boots. During the investigation, it was found that although the resident's TAR indicated that the boots were applied during all shifts from 5/14/25 to 5/18/25, progress notes from multiple staff members documented that the boots were missing and could not be located. Staff notes included reports from both nursing staff and the attending physician, who noted the resident's requests for the boots and the need to order replacements, indicating the boots were not available as required by the physician's order. The discrepancy was confirmed during a review of the records with the Director of Nursing, who acknowledged that the TAR documentation did not match the progress notes. The resident had an active order for heel protector boots to be worn at all times except during bathing, but the documentation failed to accurately reflect the resident's actual care and the absence of the boots during the specified period.