Failure to Consistently Document and Provide Nursing Treatments on TAR
Penalty
Summary
The facility failed to ensure that nursing services were provided and documented consistently on the Treatment Administration Record (TAR) in accordance with professional standards of practice. This deficiency was identified for two residents who required multiple treatments and interventions, including topical ointments for wound prevention and care, skin care, use of gel cushions and heel lifts, and regular turning and repositioning. Review of the TARs for these residents over several months revealed multiple instances where required treatments were not documented as completed, with blank entries noted for various shifts and dates. For one resident with diagnoses including morbid obesity, osteoarthritis, muscle weakness, and difficulty walking, the TAR showed missing documentation for several treatments such as application of Boudreaux's butt paste ointment, Lac-Hydrin lotion, turn and reposition every two hours, gel cushion placement, heel lifts, vitamins A and D ointment, zinc oxide cream, and pressure-relieving mattress checks. These omissions occurred across multiple dates and shifts, indicating a pattern of incomplete documentation for essential nursing interventions. A second resident, admitted with heart failure, muscle weakness, and morbid obesity, also had missing documentation for required turning and repositioning on several occasions. Interviews with the Unit Manager and Director of Nursing confirmed that nurses were expected to document treatments on the TAR after completion, and that documentation should be objective, complete, and accurate as per facility policy. However, the review of records demonstrated that this standard was not consistently met.