Failure to Document Treatments on TARs for Two Residents
Penalty
Summary
The facility failed to maintain accurate and complete medical records for two residents by not ensuring that licensed nurses documented their initials on the Treatment Administration Records (TARs) after providing prescribed treatments. For one resident, the TAR for July did not show documentation that the evening shift nurse performed the ordered sacrum cleansing and application of barrier cream on four specific dates. For another resident, the TAR lacked documentation for the cleansing and barrier cream application to the sacrococcyx and buttocks on two dates during the evening shift. These omissions were identified through medical record review and confirmed by the Director of Nursing (DON). The facility's policy and procedure required that medical records be completed and corrected in a standardized manner, with entries recorded promptly as events occur. The DON verified that after providing treatment, licensed nurses are expected to document the care provided in the resident's medical record. The absence of nurse initials on the TARs indicated that the required documentation was not completed as per facility policy, resulting in incomplete and potentially inaccurate medical records for the affected residents.