Incomplete Documentation of Resident Treatments on TAR
Penalty
Summary
Facility staff failed to ensure a complete and accurate clinical record for one of two residents reviewed, as evidenced by missing staff initials on the treatment administration record (TAR) for multiple dates. The resident involved had diagnoses including paraplegia, osteomyelitis, urinary tract infection, an indwelling catheter, and MRSA, and was noted to be cognitively intact on the most recent significant change MDS. Review of the TAR for August 2025 revealed blank spaces where staff did not indicate whether nightly dressing changes to the left heel and sacral wound were performed or refused on several dates. When questioned, facility leadership was unable to provide evidence for most of the missing documentation, except for one instance where the treatment was refused by the resident.