Failure to Document Administered Treatments on eTAR
Penalty
Summary
The facility failed to document administered treatments on the electronic Treatment Administration Record (eTAR) for a resident with multiple medical conditions, including atherosclerotic heart disease, type 2 diabetes mellitus, and anemia. The resident had an intact cognitive status and a care plan addressing behavioral challenges such as refusal of care, with interventions requiring documentation of all interactions. Physician's orders included various topical medications and wound care treatments to be administered on specific schedules. A review of the March 2025 eTAR revealed multiple blank spaces on several dates for various prescribed treatments, including clotrimazole-betamethasone cream, collagen cream, bacitracin, Dakins solution, hydrocortisone gel, mupirocin ointment, and gentamicin cream. Additionally, a required weekly skin assessment was not documented on one of the scheduled days. Corresponding progress notes did not contain any documentation explaining the missed or undocumented treatments or assessments on those dates. Interviews with nursing staff, including an RN, Nursing Supervisor, and DON, confirmed that all treatments should be documented on the eTAR and that blank spaces indicate treatments were not performed or not documented. The facility's own policy emphasized the importance of timely and accurate documentation, with no allowance for unexplained blanks. The DON verified the presence of blanks on the eTAR for the resident in question.