Inaccurate Documentation of Treatment Administration Records
Penalty
Summary
The facility failed to ensure the accuracy of Treatment Administration Records (TARs) for one resident. A review of the medical record for a resident with multiple diagnoses, including morbid obesity, psoriasis vulgaris, seborrheic dermatitis, and Type I diabetes mellitus, showed that the resident was at risk for chronic cellulitis and skin breakdown. Physician orders were in place for several topical treatments, including ketoconazole cream, miconazole powder, and triamcinolone cream, to be administered at specific intervals. The TARs indicated that these treatments were documented as administered according to the orders. However, interviews with the resident and the LPN/Unit Manager revealed that the resident was self-administering her skin treatments, and the medications were kept in her room. Nursing staff did not have an order for the resident to self-administer these treatments or to keep them at bedside. Despite this, nursing staff continued to sign off on the TARs as if they had administered the treatments themselves, without verifying whether the treatments were actually applied. The facility's policy required that the individual who administered the medication record the administration immediately after giving the medication, which was not followed in this case.