Failure to Accurately Document Turning and Repositioning on TAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete documentation on the Treatment Administration Record (TAR) for a resident who was readmitted to the facility and was coded as cognitively intact on a quarterly MDS. The resident had an order in January for turning and repositioning every 2 hours for wound management. Review of the January TAR showed multiple instances where this ordered intervention was not signed as completed, specifically on 01/02/2026 at 4:00 AM and 6:00 AM, 01/06/2026 at 6:00 PM, 01/10/2026 at 6:00 PM, and 01/28/2026 at 6:00 PM. The resident’s care plan dated 02/01/2026 included interventions to encourage or assist the resident to turn and reposition and to ensure the resident was turned and repositioned. During interviews, the resident reported having concerns in the past about not being turned and repositioned every 2 hours, although they stated that this had improved. An LPN and an RN who provided care to the resident each stated that they did turn and reposition the resident every 2 hours during their shifts, but both acknowledged they forgot to document these interventions on the TAR, with the LPN attributing this to getting busy with another resident. The DON confirmed that staff did reposition the resident every 2 hours but did not sign the TAR, and stated that staff were expected to document when treatments or interventions were completed. The Administrator also stated that the expectation was to document at the time of care so it would not be missed.
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