Incomplete Medical Record Documentation for Resident Treatment
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for one resident, as evidenced by missing documentation in the Treatment Administration Record (TAR) for April 2025. Specifically, the TAR lacked entries from licensed nurses for the application of ciclopirox external cream and wound care on two dates, as well as for the application of econazole nitrate external cream on one date. These omissions were identified during a review of the resident's physician's orders, which included specific instructions for topical antifungal treatments to the fingernails due to a fungal infection. During an interview and concurrent medical record review, the Director of Nursing (DON) confirmed the missing documentation and stated that if a licensed nurse did not document a treatment, it was considered not completed. The DON also acknowledged that she was responsible for weekly audits of the Medication Administration Record (MAR) and TAR, as the facility did not have a Medical Record Director or dedicated medical records staff. The facility's policy required objective, complete, and accurate documentation of all treatments and services performed, which was not met in this instance.