Incomplete MAR/TAR Documentation for Ordered Assessments and Treatments
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical and treatment records for one sampled resident. Facility policy on charting and documentation, last revised in July 2017, requires that all services provided, progress toward care plan goals, and any changes in a resident’s condition be documented in the medical record, and that medication administration and treatments be recorded on the MAR and TAR upon completion. Resident #2, admitted in November 2025 with diagnoses including urinary tract infection, status post fall, diabetes mellitus, and depression, had physician orders from 12/01/25 through 12/29/25 for vital signs every evening shift, daily diabetic foot care at bedtime, behavior tracking for depression every shift, and pain evaluation every shift. Review of the resident’s MAR and TAR for that period showed multiple omissions where required documentation was left blank. Vital signs on the evening shift were not documented on several specific dates in December. Diabetic foot care entries were omitted on multiple consecutive and nonconsecutive dates. Behavior tracking for depression and pain evaluations on the evening shift were also left blank on several dates. In interviews, a supervisor, a unit manager, and the DON each stated that nursing staff are expected to document daily on residents, complete the MAR and TAR as care is provided, and enter documentation upon completion of medications and treatments, but they could not explain why this resident’s records contained missing documentation.
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