F0842

E

Incomplete and Inaccurate TAR/MAR Documentation for Wound Care and Medications

Windsor, North Carolina Survey Completed on 01-13-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to maintain complete and accurate Treatment Administration Records (TARs) and Medication Administration Records (MARs) for multiple residents. For one resident with a surgical left foot incision, physician orders dated 8/26/25 directed daily and as-needed wound care using Dakin’s solution, collagen particles, Dakin’s-moistened gauze, and abdominal gauze roll. Review of the September 2025 TAR showed no documented wound care on several specific dates, despite wound care notes from 8/27/25 through 9/18/25 indicating the wound was improving. The previous Wound Care Nurse and the Assistant Director of Nursing each stated in interviews that they had completed the ordered wound care on the dates in question but had failed to document it on the TAR.

Another resident with bilateral lower extremity lymphedema had physician orders dated 4/28/25 for leg treatments twice weekly on Mondays and Thursdays, including cleansing with soap and water, application of triamcinolone, special gauze with calamine, rolled gauze, and an ace wrap from the base of the toes to one inch below the knee. TAR reviews for August, September, November, and December 2025 showed that these treatments were not marked as completed on several specific dates. Nurses interviewed, including Nurse #11, Nurse #8, and the Assistant Director of Nursing, each stated they had completed the treatments as ordered but forgot to mark them as complete on the TAR. The DON and Administrator both stated that treatments should be documented as complete in real time when finished.

For another resident with an order for Lispro insulin 3 units subcutaneously three times daily with meals, the EMAR for November 2025 showed missing nurse signatures for multiple scheduled insulin administration times. Nurses assigned on those dates stated they did not recall the specific days but indicated that if insulin had not been given, the EMAR should have been coded with a reason, and that blank EMAR boxes likely meant they had forgotten to sign. The DON and Administrator explained that the EMAR system highlights resident names in red when medications are not signed off and green when they are, and there was no stated reason for the lack of signatures. In a separate case, a resident with DM II had an order for weekly Ozempic injections; the October 2025 MAR showed documentation by a nurse that the medication was administered on a specific date and time. In a later interview, that nurse stated the documentation was an error, recalling that she had looked for the medication but could not find it, and both the DON and Administrator stated that the nurse should not have documented administration when the medication had not actually been given.