Failure to Document Nursing Services on MAR and TAR
Penalty
Summary
The facility failed to ensure that nursing services were provided and documented consistently on the Medication Administration Record (MAR) and Treatment Administration Record (TAR) in accordance with professional standards of practice. Specifically, for one resident with diagnoses including low back pain, depression, muscle weakness, and difficulty walking, there were documented blanks on the MAR for scheduled intravenous normal saline flushes and on the TAR for scheduled skin assessments with bi-weekly showers. These omissions indicate that either the care was not provided or not properly documented as required by facility policy and professional standards. Interviews and policy reviews confirmed that the expectation was for nurses to sign the treatment record after each completed treatment, and to initial the MAR after administering each medication. The Director of Nursing stated that this documentation is the only way to verify that treatments and medications have been completed. The facility's own policies reinforce the requirement for timely and accurate documentation, including the name, title, and signature of the individual providing care. The failure to document these services as required led to the identified deficiency.