Failure to Accurately Document and Implement Physician Orders for Protective Boots
Penalty
Summary
The facility failed to ensure the accuracy of a resident's medical records and the implementation of physician orders regarding the application of protective boots. A review of the medical record for a resident with multiple diagnoses, including hemiplegia, diabetes with a foot ulcer, and severe cognitive impairment, showed that the care plan and physician orders required bilateral green boots to be applied in the morning and removed at night, with legs floated on pillows twice daily. The Medication Administration Review (MAR) indicated that the boots were applied as ordered. However, during an observation, the resident was found in bed without the boots, and both an LPN and a CNA confirmed that the boots were not applied at that time, despite documentation in the MAR stating otherwise. The CNA also reported being told that the boots were to be applied at night and removed in the morning, which conflicted with the physician's orders. This discrepancy demonstrates a failure to maintain accurate medical records and to follow prescribed care interventions.